Tumours of the head and neck
IntroductionHead 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 curativeIntroduction
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 incurableIntroduction
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 cancerIntroduction
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 rareIntroduction
Surface Epithelium 1- Squamous cell Carcinoma Undifferentiated carcinoma Differentiated carcinoma Adenoid squamous carcinoma Verrucous carcinoma 2- Basal cell carcinoma 3- Malignant MelanomaIntroduction
Glandular epithelium 1- Adenocarcinoma 2- Mucoepidermoid carcinoma 3- Adenoid cystic carcinoma 4- Acinic cell carcinoma 5- Undifferentiated carcinoma
Introduction
Mesenchymal tissues Sarcoma Fibrosarcoma RhadomyosarcomaOsteogenic sarcomaChondrosarcomaNeurogenic sarcomaAngiosarcomaSynovial cell sarcomaHodgkin’s & non-Hodgkin’s lymphomas Plasmacytoma & multiple myelomaLeukaemiaMetastatic carcinoma, sarcomaIntroduction
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 transfusionIntroduction
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 userIntroduction 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 virusIntroduction
Acquired capability of cancer cell: Limitless replicative potential Evading apoptosis Self-sufficiency in growth signal Insensitive to antigrowth signals Sustained angiogenesis Tissue invasion and metastasisAssessment
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 treatableAssessment
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 treatedAssessment
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 modalityAssessment
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 examinationAssessment
The patient general condition: Assessed with full investigation and classified for performance status Grade 0 Fully active without restriction Grade 1 Ambulatory but restricted in physically strenuous activity Grade 2 Ambulatory but unable to carry out any work activity Grade 3 Confined to bed but capable of limited self care Grade 4 Confined to bed and unable to carry out any self care Karnofsky StatusAssessment
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 consideredAssessment
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 metastasisStaging
Primary Tumour:Indicated by the letter T and the suffix 1,2, 3 or 4 represent more advancing diseaseT1 – tumour 2 cm or lessT2 – tumour more than 2 but less than 4 cmT3 – tumour more than 4 cmT4 – Tumour more than 4 cm with deep invasion of underlying tissuesT0 – No evidence of primary tumourTis – Carcinoma in SituTX – Extend of primary tumour cannot be assessed
Staging
Lymph node:Is used to describe progressive lymph node involvementN1 – Single epsilateral nodes 3 cm or less in diameterN2 – Single epsilateral nodes more than 3 cm but less than 6 cm, or multiple clinically positive epsilateral less than 6 cmN2a – SingleN2b – MultipleN3 – Clinically positive epsilateral more than 6 cm, Bilateral or contralateralN3a – Epsilateral more than 6 cmN3b – Bilateral, each side staged separatelyN3c – Contralateral onlyStaging
Distant metastasis:M0 – No metastases presentM1 – Metastases clinically demonstrableMX – Metastases cannot be assessedStaging
TNM Staging:Stage I: T1, N0, M0Stage II: T2, N0, M0Stage III: T3, N0, M0 T1, 2 or 3, N1, M0Stage IV: T4, N0 or 1, M0 T1 – 4, N2 or 3, M0 T1 – 4, N1 – 3, M1 AJCC 1983Staging
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 interventionSurgical 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 diseaseSurgical 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 nodesSurgical 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 chainSurgical 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 marginSurgical 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 typeSurgical anatomy The tongue
Lymph drainage:Tip of the tongue:To the submental lymph nodes – to the lower deep cervical chainsThe anterior 2/3: the lower deep cervical chains – jugulo-omohyoid nodesSuprahyoid block dissection of no valueThe posterior 1/3:drain to the upper deep cervical chainsThe tip and middle part of the tongue have rich bilateral capillary network but less in the lateral marginsThe U-shaped floor of the mouth drain to the submandibular lymph nodesBilateral drainage from the anterior part of the USurgical 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 nodesSurgical 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 areaSurgical 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 cavitySurgical 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 nodesSurgical anatomy
The hard palate:Common location for carcinoma of the minor salivary gland Presented as smooth, rounded, bulging massesSquamous cell carcinomas present as ulcerative or exophytic lesionInvade the bone at an early stageInvolve the nasal cavity and the antrumMetastases to submandibular and upper deep cervical chainsDisease of the elderly (60 – 70 years)More commoner in menSurgical 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 nervesSurgical 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 factorSurgical anatomy The maxillary sinus
ClassificationT1 - confined to the mucosa of the infrastructureT2 - 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 muscleT4 – 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 nervesDiagnostic 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 lesionDiagnostic Techniques
Toluidine blue vital staining:Acidophilic metachromatic nuclear stain that colors sites of squamous cell carcinoma but not adjacent normal mucosa surfaces1 – 2% applied to dry surfaces and the dye diffuse into tissue through the large intercellular canaliculiDiagnostic 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 treatmentSurgical anatomy
Radiography:Routine X-Ray studies:Useful in cases of bony involvement Panoramic views shows lytic lesionsLateral soft-tissue films shows the extend into the nasopharynx or hypopharynxAngiography:Define oral malignancy – mainly avascularShows the relation to major vessels prior to surgerySelective transcatheter embolization for bleeding control or decreasing tumor vascularity preoperativelyDiagnostic 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 tumorsDiagnostic 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