Tumors of the Tumors 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

Introduction, generalWhy do we need to know about cancer?Why do we need to know about cancer?Worldwide Worldwide [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 deaths48% of 5-year-prevelent

Males 25% higher incidence rate than females

Occurred in Occurred in less developedless developed regions of the regions of the

world.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

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Introduction, general

In Malaysia In 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.

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Introduction, head and neck tumors Head and neck cancer encompasses a

broad spectrum of diseases, including malignancies of:

1. Upper aerodigestive tract2. Skin 3. Salivary glands, 4. Thyroid and parathyroid glands, 5. Tumors originating from soft tissue, bone

and neurovascular structures

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Introduction, head and neck tumorsEpidemiology [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

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[3] Bland it al. General Surgery, 2nd edition.

Introduction, head and neck tumorsEtiology: 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.

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Introduction, head and neck tumorsEtiology: in India and Southeast Asia Areca catechu tree (betel nut, quid) Destructive to the oral mucosa and

highly carcinogenic.

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Introduction, head and necktumorsEtiology: Viral agents such as Epstein-Barr virus 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

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Introduction, head and neck tumors Managment by multidisciplinary team,

including: 1. Head and neck surgeon 2. Radiation oncologist 3. Medical oncologist4. Nutritionist5. Speech pathologist 6. Social worker.

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Lip cancerUp to 98% are on the lower lip. (Why? )2% lower lip1% commissureTypes: Mainly SCCsKeratoacanthomaVerrucous carcinomaBCC (usually lower lip)MelanomaMinor salivary glands (hitiocytoma)

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Lip cancerClinicallyAn ulcerated lesion at surfaceNodular palpable lesion at deeper tissue.Paresthesias in the area near the lesion (Why? )TreatmentAccording to the stage TNM staging

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Lip cancer, TNM staging [4]

T: x, 0, is, 1, 2, 3, 4N: x, 0, 1, 2, 3M: x, 0, 1Stages:0, I, II, III, IV a,b,c

[4] AJCCS Manual 6th edition

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Lip cancer, treatment Either surgery or radiotherapy are equal

efficacy. 5-year cure rate is 90% 50% if neck metastasis Reconstruction of lip excision1. Oral competence2. Function3. Cosmosis

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Tumors of the oral cavity and oropharynx 85% of oral tumors are SCCs 15% others1. Minor salivary gland tumours2. Lymphoma3. Sarcoma4. Fibrosarcoma5. Melanoma6. Haemangioma7. Granular cell myeloblastoma

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Tumors of the oral cavity and oropharynxThey can arise from:1.Tongue (mass, loss of sensation, deviation on tongue protrusion, fasciculations and atrophy.2.Floor of the mouth3.Alveoulus/Gingiva4.Buccal mucosa5.Palate6.Oropharynx (neck lump, sore throat, ulceration, muffled “hot potato” speech, dysphagia, weight loss, referred otalgia. (Why?)

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Mediated by tympanic branches of CN IX and X

Tumors of the oral cavity and oropharynxRisk factors1.Smoking and alcohol2.Betel nut chewing3.Leukoplakia4.Dental caries5.Chronic glossitis6.Malnutrition7.Cirrhosis8.HIV

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Tumors of the oral cavity and oropharynxDiagnosis1.Clinical examination2.Panendoscopy3.X-ray (assess bone involvment) 4.CT scan and/or MRI to assess LNStagingTNM

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Tumors of the oral cavity and oropharynxManagementEarly: T1-T2 single modality, surgery or radiotherapy.Large tumour: T2-T4 Combined surgery and postoperative radiotherapy.Metastatic disease: > N1: neck dissectionChemotherapy (carboplatin, cisplatin and 5-FU) can be used.

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Hypopharyngeal carcinomaTypes: Majority are SCCSarcomas, lieomyosarcomas, adenoid cystic carcinomas and liposarcomas can occures.Clinically:DysphagiaWeight lossOtalgiaFB sensationLymphadenopathyHoarseness of voice (Why?)

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Hypopharyngeal carcinomaInvestigationsEUA and biopsyPanendoscopyCXRCT neck and chestTFTStaging is TNM

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Hypopharyngeal carcinomaManagement T1-T2: surgery (partial pharyngo-laryngectomy), radiotherapy or endoscopic resection.T3-T4: 1. Surgery: partial or total pharyngo-laryngectomy2. Reconstruction3. Radiotherapy either before or after surgeryNeck metastasisneck dissection or radiotherapy.

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Tumors of the larynxDivided anatomicallySupra-glottisGlottis (vocal cords)Sub-glottisPathologicallyBenign: papillomas, chondromas and lipomasMalignant: SCC, verrucous carcinoma, adenocarcinoma, sarcoma or undifferentiated carcinoma.

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Tumors of the larynxRisk factorsMale genderSmokingAge >40Excess alcoholClinical featuresHoarsenessCoughPalpable LNOtalgiaStridor

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Tumors of the larynxInvestigationsEUA and biopsyCXRCT scan of neckTreatmentRadiotherapy, either alone or as adjuvant +/- chemotherapyLaser resection, endoscopicallyArgon or diathermy, endoscopicallyTotal or partial laryngectomy (tracheostomy)Neck dissection

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Tumors of the neckTriangles of the Neck1.Post. Triangle2.Ant. Triangle- submental- carotid triangle- digastric triangle- muscular triangle

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Tumors of the neckLN groups

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Tumors of the neckBenign lesions:Congenital Branchial cystThyroglossal cystThymic cystDermoid cystHemangiomaLymphangioma (cystic hygroma)

AcquiredRanulaLaryngocelePharyngeal pouch

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Tumors of the neckDifferential Diagnosis1.Parotid tumor2.Swollen submandibular gland3.Thyroglossal cyst4.Branchial cyst5.Thyroid nodule6.Virchow’s node7.Carotid body tumor 8.Secondary's ….

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Thyroglossal cyst29

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?)

Thyroglossal cyst30

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 cmIndications for surgery: cosmosis, discomfort or risk of infection.

Thyroglossal cyst31

Differential diagnosis:1.Congenital dermoid cyst2.Sebaceous cyst3.Enlarged LN4.Subhyoid bursa5.Pyramidal lobe of thyroid6.Thyroid noduleComplicationsInfectionThyroglossal sinusPapillary carcinoma of ectopic thyroid tissue if present.

Thyroglossal cyst32

Treatment:USG of the neck (Why?)TFT+/- FNACSurgical excision (Sistrunk’s operation)

Thyroglossal cyst

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Thyroglossal sinus34

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.

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.

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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.

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Cystic hygromaClinical features:Usually present at birth or first few yearsPainless swelling at lower posterior triangleThink 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.

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Salivary glands Consists of: Parotid glandSubmandibular glandsSublingual glands20-80 minor glands

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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.

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Salivary glands tumors, classification

1. Adenomas Pleomorphic Adenolymphoma Myoepithelial Basal cell adenoma Ductal papilloma Cystadenoma

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2. Carcinomas Acinic cell Mucoepidermoid Adenoid cystic Carcinoma ex-pleomorphic adenoma SCC Undifferentiated

3. Non-epithelial tumors Hemangioma Lymphangioma Lipoma Neural

4. Malignant Lymphoma5. Secondary tumors6. Unclassified tumors7. Tumor-like conditions Sialometaplasia Sialoadenitis

Parotid adenomasPleomorphic adenoma80% of benign parotid gland tumorsOccurs in 5th decadeEqually in males and femalesPresent as painless, enlarging smooth mass.Adenolymphoma Age between 60-70 yearsMale:Female is 7:1Arise from tail of parotid, from lymphoid tissue.10% are bilateral.

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Signs of malignant transformation in a Parotid lump44

Involvement of the facial nerve Skin tethering Lymphadenopathy Pain Sudden growth

Parotid carcinomasAdenoid cystic carcinomaMost common malignant tumourMostly in sublingual glandsSlowly growingSpread along nerve sheath presents with facial pain and facial nerve palsy. Rarely metastasize

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Parotid carcinomasAdenocarcinoma3% of Parotid, 10% of submandibular and sublingual.20% of patients have LN metastasis at presentation.Mucoepidermoid tumorsMainly from parotidCan metastasize to LN, lungs and brain.Most common salivary glands in children.

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Parotid carcinomasCarcinoma ex-pleomorphic adenomaIt arises within a pre-existing benign pleomorphic adenoma. Estimated malignant change is 1-5% in more than 10 years.

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Staging … AJC system48

T0 no clinical evidence of tumorT1 <2 cm, no extra-parenchymal extensionT2 2-4 cm, no extra-parenchymal extensionT3 4-6 cm, and/or extra-parenchymal extensionT4a invasion of ear canal, skin, mandible or facial nT4b base of skull, or > 6 cm

Investigations 49

Blood tests ESR FBC TFT Electrophorsis SLA antibodies Renal profile LFTs RF Antinuclear factor

Radiology Plain films Sialogram CT/MRI

Histopathology No Trucut nor incisional biopsy FNAC

Surgical options 50

The aim of surgery is to remove the tumor with microscopically clear margins and preservation of Facial nerve. Superficial parotidectomyTotal conservative parotidectomyTotal radical parotidectomyExtended parotidectomy (involves removing of TMJ, mandible, zygoma or sternomastoid)Facial nerve resection (adenoid cystic carcinoma)Neck dissection.

Radiation therapy 51

Post-operative, indications:Residual diseaseExtra-capsular spread of LNHigh grade tumorsRecurrenceAdenoid cystic tumorsPeri-neural diseasePalliative RadiotherapyNon operable cases

Neurovascular and Soft Tissue Neoplasms

52Neurovascular neoplasms: 1.Carotid body tumors2.Schwannomas3.Neurofibromas 4.Paragangliomas

Soft tissue neoplasms: 1.Lipomas2.Fibrosarcomas3.Rhabdomyosarcomas4.Malignant fibrous histiocytomas 5.Dermatofibrosarcoma protuberans 6.Osteogenic sarcomas7.Leiomyosarcomas.

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.

Carotid body tumor54

References55

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 Manual 6th edition5. William’s et al. Baily and Love’s, 23rd edition. Edward

Arnold. 2008. 6. Smith et al. Essential revision notes for

intercollegiate MRCS book 2. PasTest.2002

Thank you

05/01/23

Time to Time to wake up wake up

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