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TUMOURS OF THE HEAD AND NECK

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TUMOURS OF THE HEAD AND NECK Powered By Docstoc
					Tumours of the head
    and neck
                 Introduction

• Head and neck cancer
  is remarkable for its
  ability to cause
  extensive local tissue
  destruction and regional
  node involvement in
  the absence of distant
  metastasis
                    Introduction
• Tumours are usually confined to
  the primary sites

• Regional nodes & haematogenous
  metastasis are very rare and late in
  the disease process

• Loco-regional treatment by either
  surgery, radiotherapy or
  combination of the two is
  frequently curative
                    Introduction
• Many of the oral lesions may
  have had an initial lesion that
  were potentially curable.

• The cure could be predicted if
  the lesion is diagnosed early
  and the appropriate therapy is
  given before the disease
  reaches advance stages to
  become incurable
                        Introduction
• Cancer of the oral cavity in Saudi
  Arabia is not an uncommon
  disease
• It account for more than 25% of
  all malignancies, in the Southern
  region, it might reach up to 35%
• In males, it is third in frequency
  following lung and prostate
  cancer
• In females, it is second following
  breast cancer
                 Introduction
• The spectrum of malignant tumours to affect
  the oral cavity vary widely and includes:
  • Surface epithelium
     • Squamous cell carcinoma over 90%
  • Glandular epithelium
     • Adenocarcinomas in females
     • Mucoepidermoid carcinomas in males
  • Mesenchymal tissues
     • Lymphomas, Sarcomas are very rare
                  Introduction
Surface Epithelium
  1- Squamous cell Carcinoma
      • Undifferentiated carcinoma
      • Differentiated carcinoma
      • Adenoid squamous
        carcinoma
      • Verrucous carcinoma
  2- Basal cell carcinoma
  3- Malignant Melanoma
                 Introduction
Glandular epithelium
  1- Adenocarcinoma
  2- Mucoepidermoid
  carcinoma
  3- Adenoid cystic
  carcinoma
  4- Acinic cell carcinoma
  5- Undifferentiated
  carcinoma
                          Introduction
Mesenchymal tissues
1. Sarcoma
    •   Fibrosarcoma
    •   Rhadomyosarcoma
    •   Osteogenic sarcoma
    •   Chondrosarcoma
    •   Neurogenic sarcoma
    •   Angiosarcoma
    •   Synovial cell sarcoma
2. Hodgkin’s & non-Hodgkin’s
   lymphomas
3. Plasmacytoma & multiple
   myeloma
4. Leukaemia
Metastatic carcinoma, sarcoma
                Introduction
• Prognostic Indicators:
  •   Sex: Poor prognosis in females
  •   General condition & health status of patient
  •   T stage
  •   Number of histologically positive nodes
  •   Surgical margin status
  •   Type of therapy and blood transfusion
                Introduction
• Aetiology:
  • Smoking
  • Alcohol consumption
     • They have synergistic role
     • Burning tar gives off a variety of active substances
       e.g. benzopyrene, methyl cholanthrine, which will
       be broken by arylhydrocarbon hydroxylase into
       epoxide, carcinogen, that bind to the DNA
  • Snuff dipping and Shama user
             Introduction Aetiology
• Chronic irritation from sharp jagged teeth
• Chemicals:
   • Asbestos, Nickel-Chromate, in nasal and paranasal sinuses
     tumours
   • Wood dust in Adenocarcinoma of the nose
• Dietary factors:
   • Vitamin A deficiency
   • Vitamin B deficiency, Patereson-Kelly syndrome
• Radiation exposure
• Viruses:
   •   Human Papilloma Virus HPV
   •   Epstein-Barr Virus EBV
   •   Human Immunodeficiency Virus HIV
   •   Hepatitis virus
                 Introduction
• Acquired capability of cancer cell:
  •   Limitless replicative potential
  •   Evading apoptosis
  •   Self-sufficiency in growth signal
  •   Insensitive to antigrowth signals
  •   Sustained angiogenesis
  •   Tissue invasion and metastasis
                     Assessment
• Clinical
  Examination:
  • Tumours, when first seen,
    are almost always confined
    to the head and neck with
    no distant metastasis
  • Head and neck tumours are
    rarely irremovable, all
    structures can be removed
    with the tumour in
    continuity and repaired later
      • The majority of cases are
        potentially treatable
                      Assessment
• Whether to treat or not
  depend on:
   • the age
   • the health status of the
     patient
   • advance stage
   • local disease
                   Assessment
• Full assessment will lead to
  one of the following
  conclusions:
   • Patient is potentially
     curable
   • Primary tumour is
     curable but patient
     develop another illness
   • Patient is incurable but
     should be treated
   • Patient is incurable and
     should not be treated
                Assessment
• History:
  • Age:
     • Patient are generally over 45 years.
     • Tumours affecting younger age group are usually
       sinister, defective immunological make-up
     • Most tumours are of epithelial origin and they
       require years of abuse by smoking and tobacco
     • Tumours in younger patients, who do not smoke,
       is usually very sinister
     • Tumours developing in an immuno-compromised
       patients do not respond to any treatment modality
                             Assessment
•   Complaint:
     •   Vary widely and is often
         unreliable
     •   Painless lump which persisted
         for a varying period of time
     •   Persistent ulceration
     •   Difficulty of wearing denture
     •   Later Symptoms:
          • Pain locally or referred to the
            jaw or ear
          • Difficulty with chewing food and
            swallowing
          • Altered speech and respiratory
            difficulty
     •   Asymptomatic and noticed
         during routine dental
         examination
                         Assessment
•       The patient general condition:
    •     Assessed with full investigation and classified for
          performance status
          1.   Grade 0    Fully active without restriction
          2.   Grade 1    Ambulatory but restricted in physically
                          strenuous activity
          3.   Grade 2    Ambulatory but unable to carry out any
                          work activity
          4.   Grade 3    Confined to bed but capable of limited
                          self care
          5.   Grade 4    Confined to bed and unable to carry out any
                          self care
                                                  Karnofsky Status
                Assessment
• Examination:
  • Think in term of T Staging, delineate its border
    by inspection and palpation
  • Record and draw the lesion from different
    angles using normal anatomical landmarks
  • The status of teeth should be assessed as
    causative and if radiotherapy is to considered
                  Assessment
• Staging of cancer:
  • Subdividing the malignant lesion into groups
    with similar behaviour
     • Act as a guide to appropriate treatment
     • Act as a guide to prognosis
     • Permits more reliable comparison of results
        • Primary site:
            • Histological type, size and extend of the primary
        • Node metastasis
        • Haematogenous metastasis
                         Staging
• Primary Tumour:
  • Indicated by the letter T and the suffix 1,2, 3 or 4
    represent more advancing disease
     • T1 – tumour 2 cm or less
     • T2 – tumour more than 2 but less than 4 cm
     • T3 – tumour more than 4 cm
     • T4 – Tumour more than 4 cm with deep invasion of underlying
       tissues
         • T0 – No evidence of primary tumour
         • Tis – Carcinoma in Situ
         • TX – Extend of primary tumour cannot be assessed
                           Staging
• Lymph node:
  • Is used to describe progressive lymph node
    involvement
      • N1 – Single epsilateral nodes 3 cm or less in diameter
      • N2 – Single epsilateral nodes more than 3 cm but less than 6
        cm, or multiple clinically positive epsilateral less than 6 cm
          • N2a – Single
          • N2b – Multiple
      • N3 – Clinically positive epsilateral more than 6 cm, Bilateral
        or contralateral
          • N3a – Epsilateral more than 6 cm
          • N3b – Bilateral, each side staged separately
          • N3c – Contralateral only
                    Staging
• Distant metastasis:

  • M0 – No metastases present

  • M1 – Metastases clinically demonstrable

     • MX – Metastases cannot be assessed
                        Staging
• TNM Staging:
  • Stage I: T1, N0, M0
  • Stage II: T2, N0, M0
  • Stage III: T3, N0, M0
                T1, 2 or 3, N1, M0
  • Stage IV: T4, N0 or 1, M0
                T1 – 4, N2 or 3, M0
                T1 – 4, N1 – 3, M1
                                      AJCC 1983
                       Staging
• Stage I
   • compromise negative nodes and operable primary
• Stage II
   • operable primary with operable nodes
• Stage III
   • inoperable due advanced primary or advanced nodal
     involvement
• Stage IV
   • Distant metastases preclude any surgical intervention
                 Surgical anatomy
• The Lip:
   • Covered with non-keratinized
     stratified squamous epithelium
     which is transparent, appear red,
     and contain no hair, sebaceous
     gland or pigments
   • On the vermilion border it closely
     cover the orbicularis oris muscle
     but on the lingual side mucous
     gland is present within the muscle
     and mucosa
   • The epithelium is 2 mm away from
     the muscle, ulcerative lesions will
     be fixed early in the disease
     Surgical anatomy The Lip
• Lymphatic drainage:
  • Mucosal and cutaneous systems.
  • Lower lip:
     • One medial trunk which drain the inner third of the lip into
       the submental group
     • Two lateral trunk which drain the outer two-third into the
       submandibular lymph nodes
     • Anastomosis account for bilateral metastases
  • Upper lip:
     • Drain into the periauricular, parotid, submandibular and
       submental lymph nodes
            Surgical anatomy The Lip
• Age and sex:
    • The sixth decade and Male :
      female ratio is 80:1
• 93% affect the lower lip with
  squamous cell carcinoma, exophytic
  type
• 5% in the upper lip and commonly
  basal cell carcinoma, commoner in
  females
    • Solar exposure, more radiation on
      the lower lip
    • Commoner in fair complexion
    • Smoker mainly pipe
    • In the upper lip, SCC metastasizes
      earlier than lower lip
                Surgical anatomy
• The buccal mucosa:
   • Covered with non-
     keratinizing stratified
     squamous epithelium with
     multiple minor salivary
     glands
   • It is tight over the
     buccinator muscle and fixed
     to the upper and lower sulci
   • Lymphatic drainage:
       • The submandibular
          lymph nodes to the
          lower deep cervical
          chain
                Surgical anatomy
• The tongue:
   • Specialized keratinized
     epithelium with collection
     of minor salivary gland and
     muscle fibres
   • The interlacing muscle
     fibres form an easy pathway
     for cancer spread and the
     constant movement of the
     tongue disseminates the
     disease widely
       • Excision should be wide
         with 2 cm safe margin
         Surgical anatomy The tongue
• A disease of the middle age and
  elderly with equal sex incidence
• 85% occurs in the lateral border
  of the anterior 2/3 while tip,
  dorsum and ventral surface are
  rarely involved
• The lesion may be infiltrative
  (small on the outside but
  palpation shows deep invasion)
  or exophytic and usually of the
  well-differentiated type
             Surgical anatomy The tongue
• Lymph drainage:
   • Tip of the tongue:
       • To the submental lymph nodes – to the
         lower deep cervical chains
   • The anterior 2/3:
       •    the lower deep cervical chains –
           jugulo-omohyoid nodes
             • Suprahyoid block dissection of no value
   • The posterior 1/3:
       • drain to the upper deep cervical chains
   • The tip and middle part of the tongue
     have rich bilateral capillary network
     but less in the lateral margins
   • The U-shaped floor of the mouth drain
     to the submandibular lymph nodes
   • Bilateral drainage from the anterior
     part of the U
                Surgical anatomy
• The floor of the mouth:
   • Anterior medial part:
       • Commoner than the lateral part
       • Spread medially into the ventral
         surface of the tongue and
         laterally
       • Deep spread to the base of the
         tongue and the hyoglossus and
         genioglossus muscles
       • Shows bilateral lymphatic spread
         to the submandibular and the
         submental nodes
Surgical anatomy The floor of the mouth
• Lateral part:
   • Spread medially to the side of the tongue
   • Lateral spread to the alveolar ridge where presence
     or absence of the teeth govern the outcome:
      • Teeth act as a barrier against buccal spread
      • In edentulous patient, the alveolar process has resorbed
        and cortex is incomplete, tumour reaches the cancellous
        spaces and the canal and spread through the nerve.
   • Deeper spread, mylohyoid muscle act as a barrier
     anteriorly, posteriorly the floor is close to the skin,
     appear as a palpable lump in the submandibular area
               Surgical anatomy
• The mandible:
   • Carcinoma of the lower
     alveolus affects the antero-
     lateral part and spread to the
     floor of the mouth
   • Tongue and floor of the mouth
     tumours reach the lower
     alveolus by marginal spread in
     the mucosa and submucosa
     overlying the sublingual,
     submandibular glands and the
     mylohyoid muscle.
 Surgical anatomy The mandible
• They act as barrier against deep infiltration

• Alveolar bone above the mylohyoid line is initially
  affected

• Edentulous jaws, mylohyoid line is on the occlusal
  ridge and the loss of the cortical bone barrier will
  allow tumour to spread downward into the
  medullary cavity
    Surgical anatomy The mandible

• The inferior alveolar nerve provide a pathway
  for perineural spread in a predominately
  proximal direction with little involvement of
  the bone
   • Nerve looks clinical normal till late
   • Spread is not continuous, multiple pathological
     samples is required
• Lymphatic spread to the submandibular lymph
  nodes
                 Surgical anatomy
• The hard palate:
   • Common location for carcinoma
     of the minor salivary gland
       • Presented as smooth, rounded,
         bulging masses
   • Squamous cell carcinomas
     present as ulcerative or
     exophytic lesion
       • Invade the bone at an early
         stage
       • Involve the nasal cavity and the
         antrum
       • Metastases to submandibular
         and upper deep cervical chains
   • Disease of the elderly (60 – 70
     years)
   • More commoner in men
                 Surgical anatomy
• The maxillary sinus:
   • The sinus is related to the
     orbit, nose, alveolar
     process, infratemporal fossa
     and nasopharynx.
   • It has an outlet to the nose,
     ethmoid sinuses and the
     root of the teeth
       • The posterior ethmoidal
         air cell is separated from
         the optic nerve by a bar of
         bone but it is missing in
         10% of cases and only
         encased in a sheath of
         dura, extension into the
         brain.
Surgical anatomy The maxillary sinus
 • The inferior orbital fissure provide a route for entry
   of tumours into the orbit, the periostium offer an
   excellent resistant barrier to spread into the orbit
 • The roots of the upper premolars and molars and the
   alveolus are in intimate contact to the floor
 • The infratemporal fossa is the space behind the
   maxillary antrum and it connects to the para-
   pharyngyeal space, and the sphenoid bone
   superiorly with foramen spinosium and ovale with
   their emerging nerves
    Surgical anatomy The maxillary sinus
  • Lymphatic drainage:
     •   Not fully understood
     •   Drain posteriorly to the retropharyngeal nodes
     •   Directly to the jugulo-digastric nodes
     •   If it cross to the nose or the cheek it will drain to
         submandibular lymph nodes
• Aetiology:
  • Wood dust, nickel, shoe factory and mustard
    gas
  • Snuff is a contributing factor
     Surgical anatomy The maxillary sinus
• Classification
   • T1 - confined to the mucosa of the infrastructure
   • T2 - confined to the mucosa of the suprastructure
          without bone destruction
        - confined to infrastructure mucosa with bone
          destruction of medial and inferior wall only
   • T3 - More extensive tumour invading the cheek,
          the orbit, anterior ethmoid and pterygoid
          muscle
   • T4 – Invading the cribriform plate, posterior ethmoid
     and sphenoid sinuses, nasopharynx, pterygoid plat and
     the base of the skull
     Surgical anatomy The maxillary sinus
• Malignant tumours:
   • Squamous cell carcinoma:
      • 50% of all malignant lesions of the sinus
      • Bone destruction and invasion of nose, ethmoid, orbit, anterior wall
        and cheek, and palate or alveolar ridge and buccal sulcus
   • Adenocarcinoma:
      • Uncommon, occurs in people working in wood industry
      • Histologically two types, high or low grade
      • Invade bone and present the same way like SCC
   • Adenoid cystic carcinoma:
      • Shows as solid areas of cells instead
      • Distant metastasis and perineural invasion, infra-orbital, maxillary,
        greater palatine and olfactory nerves
           Diagnostic Techniques
• Tissue Biopsy:
  • This is the mainstay of tumor
    diagnosis coupled with high
    degree of suspicion


  • Fine needle aspiration:
      • A 22-gauge needle
        attached to small volume
        syringe
      • Smear is prepared and
        stained after fixation with
        alcohol
      • Minimize tumor spillage
        and sample error in small
        lesion
       Diagnostic Techniques
• Toluidine blue vital
  staining:
   • Acidophilic metachromatic
     nuclear stain that colors
     sites of squamous cell
     carcinoma but not adjacent
     normal mucosa surfaces

   • 1 – 2% applied to dry
     surfaces and the dye diffuse
     into tissue through the large
     intercellular canaliculi
      Diagnostic Techniques
• Incisional:
   • Small portion of the lesion
     with the adjacent normal
     tissues to facilitate correct
     diagnosis
        • To visualize the
          transitional zone between
          tumor and normal tissue
        • Performed at the
          periphery to avoid the
          necrotic central area
• Excisional:
   • Removal of the entire lesion
   • Done as a primary
     treatment
              Surgical anatomy
• Radiography:
  • Routine X-Ray studies:
     • Useful in cases of bony involvement
         • Panoramic views shows lytic lesions
         • Lateral soft-tissue films shows the extend into the nasopharynx
           or hypopharynx
  • Angiography:
     • Define oral malignancy – mainly avascular
     • Shows the relation to major vessels prior to surgery
     • Selective transcatheter embolization for bleeding control or
       decreasing tumor vascularity preoperatively
      Diagnostic Techniques
• Sialography:
   • Cannulation of parotid and submandibular ducts and the
     infusiopn of contrast material
• CT-Scan:
   • Define the gross limits and determine the actual depth of tumor
   • Evaluate adjacent bony structures and erosions involving the
     paranasal sinuses, base of skull and the cervical spine
• Magnetic Resonance Imaging:
   • Gives a better resolution for soft tissue tumors
       Diagnostic Techniques
• Nuclear Scanning:
  • The use of tumor-seeking radiopharmaceutical
    material
     • Bone scanning:
        • Uses Technetium 99-labeled phosphate complexes
        • Very sensitive and positive in the presence of bony lesions
          before their detection by conventional radiographs
        • Lacks specificity, infection, inflammation and even trauma
          result in positive scan
  Diagnostic Techniques
• Salivary gland scanning:
   • I.V. Technetium shows an increased uptake in papillary
     cystadenoma.
   • Might occur with other benign or malignant tumors as a
     focal areas
• Gallium-67 scanning:
   • Gallium isotopes concentrate in a rapidly growing tumors
   • Best in epidermoid carcinomas and lymphomas
   • Used in lymphoma staging
        Diagnostic Techniques
• Tumor markers:
  • Tumor markers are molecules occurring in blood or
    tissue that are associated with cancer and whose
    measurement or identification is useful in patient
    diagnosis or clinical management.
  • Tumor markers are most useful for monitoring response
    to therapy and detecting early relapse
  • They are generally products of the cancer cell, although
    none is unique to cancer cells; they represent aberrant
    tumor production of a normal element
     Diagnostic Techniques
• Tumor markers can be used for one of four
  purposes:
   • 1- screening a healthy population or a high risk
     population for the presence of cancer
   • 2- making a diagnosis of cancer or of a specific type
     of cancer
   • 3- determining the prognosis in a patient
   • 4- monitoring the course in a patient in remission or
     while receiving surgery, radiation, or chemotherapy.
        Diagnostic Techniques
• Carcinoembryonic Antigen “CEA”
  • The CEA was one of the first oncofetal antigens to be
    described and exploited clinically.
  • It is a complex glycoprotein and is associated with the
    plasma membrane of tumor cells, from which it may be
    released into the blood.
  • The primary use of CEA is in monitoring colorectal
    cancer, especially when the disease has spread and to
    check recurrence
  • Other cancers produce elevated levels of this tumor
    marker, including lymphoma, head and neck cancer and
    cancers of the breast, lung, pancreas

				
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