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02 msu tumors of head and neck hajhamad m
1. Tumors of theTumors of the
head and neckhead and neck
Dr. Mohammed Hajhamad. MB.B.CH, MS.Dr. Mohammed Hajhamad. MB.B.CH, MS.
Thursday
31st
Dec 2015
2. Introduction, general
Why do we need to know about cancer?Why do we need to know about cancer?
WorldwideWorldwide [1][1] ……
14.1 million new cancer cases reported
8.2 million deaths
32.6 million people living with cancer (within 5
years of diagnosis)
57% of new cases
65% of deaths
48% of 5-year-prevelent
Males 25% higher incidence rate than females
Occurred inOccurred in lessless
developeddeveloped regionsregions
of the world.of the world.
[1] international agency for research on cancer, All cancers (excluding non-melanoma skin cancer): estimated incidence, mortality and prevalence
worldwide in 2012. http://globocan.iarc.fr
2
3. Introduction, general
In MalaysiaIn Malaysia [2][2] ……
21,773 Malaysians diagnosed with cancer in
2007.
10,000 unregistered each year.
One – in – 4 Malaysian will develop cancer by
age of 75.
Malaysian females have higher incidence
compared to males 1.2:1
[2] National Cancer Society Malaysia, cancer in Malaysia. http://cancer.org.my/learn-about-cancer.
3
4. Introduction, head and neck tumors
Head and neck cancer encompasses a broad
spectrum of diseases, including malignancies
of:
1. Upper aerodigestive tract
2. Skin
3. Salivary glands,
4. Thyroid and parathyroid glands,
5. Tumors originating from soft tissue, bone and
neurovascular structures
4
5. Introduction, head and neck tumors
Epidemiology [3]Epidemiology [3]
USA, head and neck cancers account for 3% of
all new cancers and 2% of all cancer deaths
annually.
Worldwide, it is the fifth most common cancer,
6% of all new cancer cases and 5.2% of all cancer
deaths.
Male more than females
5
[3] Bland it al. General Surgery, 2nd
edition.
6. Introduction, head and neck tumors
Etiology:
Smoking and alcohol (most important)
2 packs/day + 4 units alcohol = 35 folds higher risk
Passive smoking = 4 folds higher risk
Smoking and alcohol cause mutation in p53-specific
for aerodigestive tract tumors.
40% of patients who didn’t stop smoking after
treatment developed either recurrence or new head
and neck malignancy.
6
7. Introduction, head and neck tumors
Etiology:
in India and Southeast Asia
Areca catechu tree (betel nut, quid)
Destructive to the oral mucosa and highly
carcinogenic.
7
8. Introduction, head and neck tumors
Etiology:
Viral agents such as Epstein-Barrvirus and human papilloma
virus have been associated with an increased risk of developing
nasopharyngeal and oropharyngeal cancer.
Other risk factors
1. nutritional
2. occupational (nickel, wood dust, solvents),
3. prior history of head and neck radiation,
4. immunosuppression and predisposing conditions.
5. Mucosal changes, leukoplakia and erythroplakia are
premalignant lesions.
6. Ultraviolet rays
8
9. Introduction, head and neck tumors
Managment by multidisciplinary team,
including:
1. Head and neck surgeon
2. Radiation oncologist
3. Medical oncologist
4. Nutritionist
5. Speech pathologist
6. Social worker.
9
10. Lip cancer
Up to 98% are on the lower lip. (Why? )
2% lower lip
1% commissure
Types:
Mainly SCCs
Keratoacanthoma
Verrucous carcinoma
BCC (usually lower lip)
Melanoma
Minor salivary glands (hitiocytoma)
10
11. Lip cancer
Clinically
An ulcerated lesion at surface
Nodular palpable lesion at deeper tissue.
Paresthesias in the area near the lesion (Why?
)
Treatment
According to the stage
TNMstaging
11
12. Lip cancer, TNMstaging [4]
T: x, 0, is, 1, 2, 3, 4
N: x, 0, 1, 2, 3
M: x, 0, 1
Stages:
0, I, II, III, IV a,b,c
[4]AJCCS Manual6 th
e ditio n
12
13. Lip cancer, treatment
Either surgery or radiotherapy are equal efficacy.
5-year cure rate is 90%
50% if neck metastasis
Reconstruction of lip excision
1. Oral competence
2. Function
3. Cosmosis
13
14. Tumors of the oral cavity and
oropharynx
85% of oral tumors are SCCs
15% others
1. Minor salivary gland tumours
2. Lymphoma
3. Sarcoma
4. Fibrosarcoma
5. Melanoma
6. Haemangioma
7. Granular cell myeloblastoma
14
15. Tumors of the oral cavity and
oropharynx
They can arise from:
1.Tongue (mass, loss of sensation, deviation on tongue
protrusion, fasciculations and atrophy.
2.Floor of the mouth
3.Alveoulus/Gingiva
4.Buccal mucosa
5.Palate
6.Oropharynx (neck lump, sore throat, ulceration, muffled
“hot potato” speech, dysphagia, weight loss, referred
otalgia. (Why?)
15
Mediated by tympanic branches of CN IXand
X
16. Tumors of the oral cavity and
oropharynx
Riskfactors
1.Smoking and alcohol
2.Betel nut chewing
3.Leukoplakia
4.Dental caries
5.Chronic glossitis
6.Malnutrition
7.Cirrhosis
8.HIV
16
17. Tumors of the oral cavity and
oropharynx
Diagnosis
1.Clinical examination
2.Panendoscopy
3.X-ray (assess bone involvment)
4.CT scan and/or MRI to assess LN
Staging
TNM
17
18. Tumors of the oral cavity and
oropharynx
Management
Early: T1-T2 single modality, surgery or
radiotherapy.
Large tumour: T2-T4 Combined surgery and
postoperative radiotherapy.
Metastatic disease:
> N1: neck dissection
Chemotherapy (carboplatin, cisplatin and 5-FU)
can be used.
18
19. Hypopharyngeal carcinoma
Types:
Majority are SCC
Sarcomas, lieomyosarcomas, adenoid cystic
carcinomas and liposarcomas can occures.
Clinically:
Dysphagia
Weight loss
Otalgia
FB sensation
Lymphadenopathy
Hoarseness of voice (Why?)
19
21. Hypopharyngeal carcinoma
Management
T1-T2: surgery (partial pharyngo-laryngectomy),
radiotherapy or endoscopic resection.
T3-T4:
1. Surgery: partial or total pharyngo-laryngectomy
2. Reconstruction
3. Radiotherapy either before or after surgery
Neck metastasis
neck dissection or radiotherapy.
21
22. Tumors of the larynx
Divided anatomically
Supra-glottis
Glottis (vocal cords)
Sub-glottis
Pathologically
Benign: papillomas, chondromas and lipomas
Malignant: SCC, verrucous carcinoma,
adenocarcinoma, sarcoma or undifferentiated
carcinoma.
22
23. Tumors of the larynx
Riskfactors
Male gender
Smoking
Age >40
Excess alcohol
Clinical features
Hoarseness
Cough
Palpable LN
Otalgia
Stridor
23
24. Tumors of the larynx
Investigations
EUA and biopsy
CXR
CT scan of neck
Treatment
Radiotherapy, either alone or as adjuvant +/-
chemotherapy
Laser resection, endoscopically
Argon or diathermy, endoscopically
Total or partial laryngectomy (tracheostomy)
Neck dissection
24
25. Tumors of the neck
Triangles of the Neck
1.Post. Triangle
2.Ant. Triangle
- submental
- carotid triangle
- digastric triangle
- muscular triangle
25
28. Tumors of the neck
Differential Diagnosis
1.Parotid tumor
2.Swollen submandibular gland
3.Thyroglossal cyst
4.Branchial cyst
5.Thyroid nodule
6.Virchow’s node
7.Carotid body tumor
8.Secondary's ….
28
29. Thyroglossal cyst
29
It’s a portion of the “thyro-glossal duct” which
remained patent. (What is that?)
Dilatation along the duct, the rest may or may
not be obliterated.
Its closely related to hyoid bone. (So what?)
Lined with stratified squamous epithelium or
pseudo-stratified epithelium.
May contain thyroid or lymphoid tissue.
(What is the clinical implications?)
30. Thyroglossal cyst
30
Clinically:
Can appear at any age. Average age is 5
years, 40% within first 10 years.
Equally common in boys and girls.
90% present as midline swelling that elevate
with tongue protrusion.
Usually painless, once infected, becomes
painful, tender and enlarged.
Size between 0.5 – 5 cm
Indications for surgery: cosmosis, discomfort or
risk of infection.
34. Thyroglossal sinus
34
15% appear at presentation.
Developed after rupture of the cyst or after
surgery.
Its not a fistula (unlike branchial sinus) (Why?)
Clinically: there is a sinus opening on the
neck, usually midline, +/- scar.
The cyst may or may not be palpable.
35. Branchial cleft cyst and sinuses
Its due to failure of complete growth of 2nd
pharyngeal arch over 3rd
and 4th
clefts.
Most common, 2nd
branchial cleft sinus,
Present as opening of skin anterior to SCM at
the junction between middle and lower 3rds.
The tract passes between ICA and ECA to
terminate in the tonsillar fossa.
Treatment: surgical excision, if symptomatic.
35
37. Cystic hygroma
Normally, lymphatic system developed by
coalescence of multiple small lymph vesicles.
If vesicles of jagular lymph sac fail to join lymphatic
system sequestrated form cystic hygroma.
Most common in the neck
Can happen in cheek, tongue, axilla, mediastinum or
groin.
Consists of multiple cysts of different sizes.
Each cyst lined by endothelial cells and contain clear
lymph.
37
38. Cystic hygroma
Clinical features:
Usually present at birth or first few years
Painless swelling at lower posterior triangle
Think skin covering and translucent to light.
Swelling is soft, partially compressible with increase in
size during coughing and crying.
May grow rapidly and interfere with respiration.
Treatment is surgical excision.
38
41. Salivary glands tumors
Benign or malignant
80% of all salivary glands tumors occur in
Parotid.
80% of all parotid tumor are benign
80% of all parotid benign tumors are
pleomorphic adenoma.
33% of submandibular gland tumors are
malignant.
50% of sublingual gland tumors are malignant.
41
43. Parotid adenomas
Pleomorphic adenoma
80% of benign parotid gland tumors
Occurs in 5th
decade
Equally in males and females
Present as painless, enlarging smooth mass.
Adenolymphoma
Age between 60-70 years
Male:Female is 7:1
Arise from tail of parotid, from lymphoid tissue.
10% are bilateral.
43
44. Signs of malignant transformation
in a Parotid lump
44
Involvement of the facial nerve
Skin tethering
Lymphadenopathy
Pain
Sudden growth
45. Parotid carcinomas
Adenoid cystic carcinoma
Most common malignant tumour
Mostly in sublingual glands
Slowly growing
Spread along nerve sheath presents with
facial pain and facial nerve palsy.
Rarely metastasize
45
46. Parotid carcinomas
Adenocarcinoma
3% of Parotid, 10% of submandibular and
sublingual.
20% of patients have LN metastasis at
presentation.
Mucoepidermoid tumors
Mainly from parotid
Can metastasize to LN, lungs and brain.
Most common salivary glands in children.
46
47. Parotid carcinomas
Carcinoma ex-pleomorphic adenoma
It arises within a pre-existing benign
pleomorphic adenoma.
Estimated malignant change is 1-5% in more
than 10 years.
47
48. Staging … AJC system
48
T0no clinical evidence of tumor
T1<2 cm, no extra-parenchymal extension
T22-4 cm, no extra-parenchymal extension
T34-6 cm, and/or extra-parenchymal extension
T4a invasion of ear canal, skin, mandible or
facial n
T4b base of skull, or > 6 cm
50. Surgical options
50
The aim of surgery is to remove the tumorwith
microscopically clearmargins and preservation of Facial
nerve.
Superficial parotidectomy
Total conservative parotidectomy
Total radical parotidectomy
Extended parotidectomy (involves removing of TMJ,
mandible, zygoma or sternomastoid)
Facial nerve resection (adenoid cystic carcinoma)
Neck dissection.
53. Neurovascular and Soft Tissue
Neoplasms
53
Carotid body neoplasm is most common
The diagnosis should be suspected strongly by their
location.
Biopsy is contraindicated because of their vascularity.
Size, shape, consistency, and fixation are important
factors to note on physical examination.
MRI and CT scan is best diagnostic modality, unless
angiogram required.
Treatment involves resection with sparing of the
vasculature (carotid body neoplasms) or nerve
(schwannoma) whenever possible.
55. References
55
1. International agency for research on cancer, All cancers
(excluding non-melanoma skin cancer): estimated incidence,
mortality and prevalence worldwide in 2012.
http://globocan.iarc.fr
2. National Cancer Society Malaysia, cancer in Malaysia.
http://cancer.org.my/learn-about-cancer.
3. Bland it al. General Surgery, 2nd
edition. Springer. 2009
4. AJCCS Manual6 th
e ditio n
5. William ’s e t al. BailyandLove’s, 23rd
e ditio n. Edward Arno ld.
20 0 8 .
6 . Sm ith e t al. Essential revisionnotes forintercollegiateMRCS
book2. PasTe st. 20 0 2