Head and neck cancer

Classification

· SCC 90%

· minor salivary gland cancer

— mainly on the hard palate ~10%

· melanoma

· sarcoma

· lymphoma

· metastatic

Diagnosis

· First Confirm the Diagnosis via biopsy of primary (especially in oral cavity of oropharynx) or FNA of neck metastasis.

· After confirmation of diagnosis, staging is required. This requires complete examination and biopsy under GA (flexible videolaryngoscopy is not a substitute).

· Direct laryngoscopy (+/- microscopy)

· Direct esophagoscopy

· Direct tracheobronchoscopy

· This is important because of the rate of synchronous primary tumours of 5-15%.

· When the primary lesion is digestive tract (oral cavity, oropharynx and hypopharynx) the second lesion is usually in the digestive tract

· When the primary lesion is in the larynx, the second primary is usually in the respiratory tract (lungs and main stem bronchus).

The information from office examination and panendoscopy is combined for stgaing

General Staging

TNM

· T

— T1 <2cm

— T2 2-4cm

— T3 >4cm

— T4 involving adjacent bone or muscle

· N

— N1 Single ipsilateral LNM £3cm

— N2

            a Single ipsilateral LNM 3 - 6cm

            b Multiple ipsilateral £ 6cm

            c Bilateral £6cm

— N3 ³6cm

· M

— M1 distant mets present

- common distant mets sites are lung (66%), Bone (22%), liver (10%)

- uncommon distant mets in skin, mediasternuem, Bone marrow

Staging

· Stage I T1 N0 M0

· Stage II T2 N0 M0

· Stage III T3 N0-1 M0

· Stage IV T4, N2-3, M1

General treatment guidelines

· Plan treatment in MDT setting

· Cessation of alcohol and tobacco use critical; if continue to do so,

            40% risk of local recurrence

            40% risk of new primary

· Optimization of medical, nutritional and psychological status

· Stage I/II lesions: both primary surgery and radiotherapy produce equal rates of control

· Ad surgery: reserves radiotherapy for recurrent or sequential malignancy. Allows removal of primary and occult nodal disease in a short period of time

· Ad XRT: minimal functional disturbance is produced so suited to larynx or hypopharynx cancer.

· Stage III and IV lesions are usually approached with multimodality treatment

· Surgery with post-op chemo and RT for high recurrent risk patients (two or more nodes involved, extra-capsular extension of nodal disease, microscopic positive margins).

· Contra-indications to surgery:

            Scattered dermal metastasis that cannot be encompassed in excision

            Solid fixation to skull base with intra-cranial extension

            Fixation to cervical spine.

· Distant metastatic disease is treated with palliative Cis-platin and 5-FU.

Sites

Oral cavity:

· Lip, buccal mucosa, floor of mouth and tongue

Pharynx:

· Oropharynx, nasopharynx, hypopharynx

Larynx

· Supra glottic, glottic and subglottic

Incidence

· 26/100 000/ yr in men in the USA; 8/ 100 000/ yr in women (300 per million and 80 per million)

· 5% of all cancers

· peak age at presentation 55-65yr

· 1/3 who develop it will die from it

Risk factors

· Age >45yr (rare before this age)

· Male > Female

· Environmental

— cigar and pipe smoking RR4x; cigarretes less so (lung cancer rates have increased 5x in 50yrs whereas oral cancer has halved)

— reverse smoking

— Alcoholics have RR 6x (acts synergistically with cigarrettes)

Alcohol and tobacco account for 80% of all cancers in upper aerodigestive tract.

Specific aetiological factors pre-dispose to disease in certain sites

Skin

—   sunlight predisposes to cancer of the lower lip

—   Neoprene

—   Burns

—   Riboflavin deficiency

Nose and paranasal sinuses

—   Wood dust

—   Nickel refining

—   Leather manufacturing

Nasopharynx

—   EBV type II and III

—   Nirtosamine

—   Salted fish

—   Vitamin deficiency

Oral cancer

—   Betel nut and tobacco chewing

· Indians - account for 50% of all cancers in some places (5% in the West)

—   Reverse smoking

—   Syphilis

— ?oral hygiene

— ?vitamin deficiences

Larynx and hypopharynx

Asbestos, coke, wood dust, riboflavin deficiency

· Familial ?

· Syndromes

— Plummer-Vinson (along with post cricoid cancers)

· Precursor lesions

— submucous fibrosis (Indians) affecting the palate and buccal mucosa; 50% get Ca

— leukoplakia - 5% get invasive Ca (15% have dysplasia and 80% benign hyperkeratosis only)

Pathology

Distribution & Prognosis

Macroscopic

· ulcer with sloughy base and surrounding induration

· may be protruberant or flat

Microscopy

· well differentiated SCC

            · epithelial nests

            · keratin pearls

            · majoritity are intermediate grade

                        grading seldom contributes to managment

· poorly differentiated lesions may be difficult to distinguish from lymphoma and metastases

Sites

Lip

· 90% occur on lower lip between midline and lateral commisure

· Stage I and II (<4cm) can be treated with wide excision and primary closure

· Neck dissection required for known neck disease or T3/T4

· Post-op RT required for stage III or IV disease of perineural/perivascular invasion or recurrent disease

Tongue

· High risk of lymph node mets therefore neck dissection undertaken for any lesion with >2mm of invasion.

· Lesions excised with a 2cm margin

· Lateral lesions of the tongue that do not involve the floor of the mouth can be reconstructed with SSG

· If the floor of the mouth, hemi tongue or mandible resection is involved then microvascular free tissue transfer is usually optimal (free radial forearm flap).

Floor of mouth

· Surgery is treatment of choice

· Mandible is involved at any early stage and bilateral submandibular region metastasis often occur.

· The treatment of choice is wide local excision often combined with mandibulectomy, bilateral neck dissections.

· Reconstruction with microvascular free tissue transfer is required if there is a mandibular defect or a through-and-through defect in the floor of the mouth.

Buccal mucosa

· Aggressive lesions occurring in men >70 years

· Associated with smoking and chewing tobacco and betel nut and a history of lichen planus

· Often involve the mandible and 50% risk of cervical node metastasis

· Stage I/II lesions treated with XRT alone to primary and neck

· Stage III/IV lesions treated with surgery followed by XRT.

· Through-and-through defects in the cheek are reconstructed with microvascular free tissue transfer.

Oropharynx

· Extends from the soft palate to hyoid bone and includes base of tongue

· Tonsil and tonsillar fossa (50%) are the most common sites; base of tongue (20%) have worse prognosis.

· Stage I/II lesions are treated with XRT or chemo-RT as it produces equivalent outcomes with less functional disturbance

· Stage III/IV lesions treated with surgery and XRT combined.

· Surgery often impairs ability to swallow and gag reflex.

· Reconstruction with microvascular free tissue transfer often required (Free radial forarm flap).

Nasopharynx

· From skull base to level of hard palate. Most common site is fossa of Rosenmuller.

Common in china and hong kong

· Bimodal incidence with peaks in teenage years and 50’s

· Aetiology: EBVinfection combined with nitrosamines from salted fish, Nickel, polycyclic hydrocarbon and chronic sinusitis.

· WHO type 1: resemble SCC and is the most common in European: 25%

· WHO type 2: Transitional carcinoma including lymphepithelial and squamous elements without keratinization: 12%

· WHO type 3: Undifferntiated also non-keratinizing known as lymphoepithelioma. Endemic in SE asia and EBV associated: 65%. Most radiosensitive.

· Symptoms:

Palpable neck mass (65% of patients  – 20% bilateral),

unilateral conductive hearing loss (obstruction of Eustachian tube)

unilateral elevation of soft palate

pain in side of head from infiltration of trigeminal nerve at foramen lacerum

nasal obstruction

epistaxis

· Treatment is RTx to primary site and neck.

Hypopharynx

· Mucosal area lateral to larynx, inferior to hyoid bone to level of cricopharyngeus.

· Aggressive cancer is men 60-80 years

· Alcohol, tobacco, Plummer-Vinson syndrome and GORD are aetiological factors.

SCC

· Present with odynophagia, dysphagia, referred otalgia and neck mass.

· 75% have neck metastasis at presentation

· Stage I and II lesions treated with XRT

· Advanced lesions are treated with surgery (total laryngectomy and microvascular free tissue transfer reconstruction of the pharynx) and post op-RT.

· Chemo-RT can offer similar outcomes to surgery with better organ preservation.

Larynx cancer

· Supraglottic larynx: from vallecula to the laryngeal ventricles

· Glottic: inferior portion of ventricle, true vocal cord and the portion of the superior       subglottis (1cm below the true vocal cord)

· Subglottic: Region from 1cm below the true vocal cord to the first tracheal ring.

· Symptoms: Hoarse voice, dysphagia/odynophagia (supraglottic), referred otalgia, neck masses, cough, stridor for subglottic.

· Supraglottic 35% - occur in vallecula, false cords, ventricle and arytenoids. 40% cervical LN mets. 5 year survival 65%

· Glottic 65% - Occur in the anterior and posterior commissures of the true vocal cords. Cervical LN mets are unusual and 5 year survival rate is 80%.

· Subglottic <5%  - occur in walls of subglottis. 20% have LN mets at presentation and five year survival is 40%

· Transglottic tumours <5%

Staging

· Each subsite of the larynx has a separate staging system. However in general terms

T1: limited to one sub-site of the larynx

T2: involves more than one subsite of the larynx with or without impaired vocal cord mobility

T3: Vocal cord fixation

T4: Invasion beyond larynx: Oropharynx, hypopharynx, tongue, soft tissue of the neck or thyroid.

· Stage I/II

            XRT and surgery produce similar outcomes with better function after XRT as       voice is retained.

· Stage III/IV

            Total laryngectomy with bilateral neck dissection and post-op RT is the         traditional treatment.

            Recent studies have shown that induction or concurrent chemo-RT produce           similar survival with higher rates of organ preservation than surgery

· Residual or recurrent disease after RT is treated by total laryngectomy and RND

Special cases

· Supraglottic cancers

Early lesions stage I/II can be treated with endoscopic CO2 laser resection or open supraglottic laryngectomy with neck dissection. Supra cricoids-laryngectomy can also be performed for T1-T3 cancers.

XRT to neck is recommended as there is a high rate of occult nodal mets.

· Glottic cancers

l   Early T1 glottic cancers can be treated with microsurgical dissection with results equivalent to XRT

l   T1 lesions not involving the anterior commissure can be treated with CO2 laser with XRT held in reserve for recurrence.

l   T1 or T2 lesions of the vocal cord may be treated with open hemilaryngectomy with significant disruption to phonation for which reason XRT is preferred.

l   For Tis, vocal cord striping or CO2 laser can be used

· Subglottic cancers

Stage I/II lesions treated with XRT with surgery for advanced disease

Surgery is total laryngecotmy, partial resection of trachea, bilateral neck dissection, paratracheal and mediastinal neck dissection.

Clinical

Trotter’s Syndrome

· nasopharyngeal Ca

· involvement of the foramen ovale and pressure on the mandibular nerve

· pain in lower jaw; assymetry of the soft palate; deafness; lockjaw (trismus) may develop

Surgery

· for small lesions is quick and involves only one treatment

Options

· cheek flap (upper or lower) if large or posterior

· segmental mandible resection if mandible involved

· the jaw split at the symphysis useful for base of tongue lesions

· lateral osteotomy posterior lesions of the base of tongue or oropharynx

· Neck dissection

— Elective

— therapeutic

Complications

· break down of wound

· exposure of the carotid following #1

· slurring of speech

· swallowing impairment

· drooling

Radiation

· RT alone is as effective as surgery for stage I and II SCC of the oral cacity

· otherwise needs surgery unless very advanced in which case palliative RT is required

· is as effective pre or post op

· wound healing with 40-60gy is less of an issue with postop RT

· can be done as brachytherapy

Indications

· T3 or T4 tumours

· extensive nodal involvement

· extrnodal disease

· poor prognostic features - vessel invasion; involved margins

· obvious nodal disease requires resection rather than irradiation

Complications

· Persistant ulceration

· Osteoradionecrosis of the mandible (with tooth loss)

Prognosis

· 1/3 will die of their disease

· single node involvement halves the survival

· multiple node involvement s seldom curable

Follow up

· most recurrences are within the first 3yrs

· 20% incidence of synchronous or metachronous aerodigestive Ca

Miscellaneous lesions of oral cavity

Apthous ulcers

· recurrent crops of shallow ulcers in the oral cavity

· minor form

— small

— heal without scarring

· major form

— large

— scars form

· most are idiopathic (trauma, stress)

· some are associated with other disease

— CD

— UC

— Bechet’s syndrome (uveitis, aphthous ulcers of the oral mucosa & genitalia; diffuse vasculitis; usually young males)

Crohn’s disease

· 10% have oral CD only on presentation

· granulomata with lymphocytic infiltrate

· cobble stoning +/- painful ulceration of the oral mucosa

· may precede any other manifestation (cf. perianal disease)

Geographic tongue

· smooth red areas due to the atrophy of the fuliform papillae

· harmless

· unknown etiology

Median rhomboid glossitis

· red rhomboid or oval patch devoid of filiform papillae

· may be due to Candida; may be a failure of withdrawal of the tuberculum impar before fusion of the lateral halves of the tongue

Dermoid cyst

· 2% occur in the floor of the mouth

· usually young patients

· if above the geniohyoid ® presents in mouth

· if below the geniohyoid ® presents in submental triangle

Epulis

· tumour-like conditions of the gum

H&N 37

Giant cell

· small mass in the subepithelial connective tissue of the gum

· may be pedunculated

· mixture of spindle and giant cells

· does not recur if excised

Congenital

· newborn

· anterior maxilla

· M:F = 10:1

· soft sessile or peduculated mass

· does not recur

Granular cell tumours (myoblastoma)

· any age

· positive for s100

· painless circumscribed mass

· histologically similar to congenital epulis

· usuall benign can recur and even metastasise (malignant granular cell tumour)

What are the zones in penetrating neck trauma

• zone I – below cricoid

• zone II – cricoid to angle of mandible

• zone III – above angle of mandible

What are the features of immediately life-threatening neck injuries

• massive bleeding

• expanding haematoma

• non-expanding haematoma with haemodynamic instability

• haemomediastinum

• haemothorax

• hypovolaemic shock

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What is the approach to penetrating neck trauma

• clinical assessment for injuries

• airway

• respiratory distress

• stridor

• cyanosis

• haemoptysis

• hoarseness

• tracheal deviation

• subcutaneous emphysema

• sucking wound

• vascular

• haematoma

• persistent bleeding

• neurologic deficit

• absent pulse

• hypovolaemic shock

• bruit

• thrill

• change of sensorium

• nervous system

• hemiplegia

• quadriplegia

• coma

• cranial nerve deficit

• change of sensorium

• hoarseness

• oesophagus/hypopharynx

• subcutaneous emphysema

• dysphagia

• odynophagia

• haematemesis

• haemoptysis

• tachycardia

• fever

• intervention for unstable patients

• zone I – median sternotomy for R-sided injuries, L thoracotomy for L

• zone II – neck exploration

• zone III – angiography ± exploration

• investigation with selective exploration for stable patients

• angiography zones I and III (zone II observation vs exploration vs.

angiography)

• GG swallow, ± endoscopy

• bronchoscopy

• CT scan neck/chest

• CXR