Head & Neck Cancer Diagnosis

7/29/2019 Head & Neck Cancer Diagnosis

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Head & Neck Cancer Diagnosis

Surgeon PerspectiveSunarto Reksoprawiro

Department of Surgery

Faculty of Medicine, Airlangga University/ Dr. Soetomo Hospital

Surabaya


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INTRODUCTION

Head and neck cancer

oral cavity

pharynx

paranasal sinuses

nasal cavity

larynx

salivary glands


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EPIDEMIOLOGY

US (1992) : 42,800 cases of head and neckcancer with 11,600 deaths.

Worldwide : more than 500,000 new cases

are projected annually


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RISK FACTORS

Tobacco

Alcohol

Occupational risk factors : nickel refining

woodworking

exposure to textile fibers Epstein-Barr virus

Radiation


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PATHOLOGY

squamous cell carcinomas (95%)

lymphoepithelioma spindle cell carcinoma

verrucous cancer

undifferentiated carcinoma lymphoma


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BIOLOGY

Squamous-cell carcinomas (95%)

Field of cancerization (upper aerodigestive tract,

lungs, and esophagus) Multistep process of carcinogenesis

Deletion of chromosom 3p, 18q

Amplification of EGFR, int-2, bcl-1

p53 mutation Alterations in differentiation antigens (cytokeratins,

envelope proteins, blood-group antigens and otherglycoproteins) occur in later stages of carcinogenesis


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ORAL CANCER(50% OF HEAD AND NECK CANCER)

incidence : 3% (males) and 2% (females) of all

malignant neoplasms

5 YSR : 50%


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PREMALIGNANT LESIONS

Leucoplakia

Erythroplakia


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SIGNS AND SYMPTOMS OF ORAL CANCER Mouth sore that does not heal within 2-3 weeks

Mouth sore that bleed spontaneously

Velvety white, red, or speckled (red and white) patchon the mouth that is persistent

Hard, raised lesion (lump, crust, eroded areas on thelips gums, or other area inside the mouth

Unexplained bleeding in the mouth

Persistent pain in the mouth Difficulty chewing, swallowing, speaking, or moving

the tongue


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PHYSICAL EXAMINATION

Adequate light source

Mouth mirror is essential

Forceful protraction of the tongue


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Primary tumor

Inspection Palpation

Sign of malignancy

Site / location Infiltration/ invasion to the surrounding tissue

T determination


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The Growth Form

Exophytic/ Fungating

Infiltrative

Ulcerative Cancer of the lip (95% lower lip, slow growing)


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ORAL CANCER

Cancer of the tongue


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Cancer of the gum

Cancer of the buccal mucous


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Cancer of the palate

Cancer of the mouth floor


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Regional Lymph nodes

Inspection Palpation

Site/ location/ level

Size, consistency, mobility

N determination


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Head and neck lymph drainage


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CLINICAL DIAGNOSIS


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DIAGNOSTIC TESTS

BIOPSY

CYTOLOGY

Scraping / brushing ( for superficial ulcerative lesion )

FNAB ( for mass lesion)

TISSUE BIOPSY

Excisional biopsy ( for lesion < 1 cm ) Incisional biopsy ( for lesion > 1 cm )


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IMAGING

Extention of primary tumor (T)

Panoramic, Waters

CT scan, MRI
http://www.google.com/imgres?imgurl=http://download.imaging.consult.com/ic/images/S1933033208836245/gr94-midi.jpg&imgrefurl=http://imaging.consult.com/image/chapter/Head%20and%20Neck?title=Oral%20Cavity&image=fig94&locator=gr94&pii=S1933-0332(08)83624-5&usg=__fNm7rI4x8jg7Pd9uF_oBeyDYZPU=&h=183&w=200&sz=6&hl=en&start=19&zoom=0&tbnid=B15AXYBZg8JFmM:&tbnh=95&tbnw=104&ei=w2yHTeTbN9CGrAeu0Ogt&prev=/images?q=tongue+carcinoma,+CT+scan+OR+MRI&hl=en&sa=G&gbv=2&tbs=isch:1&itbs=1


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Cervical lymph nodes metastasis (N)

USG, CT scan, MRI


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Distant metastasis (M)

Chest X ray photo

USG upper abdomen

Tc scan, PET scan
http://www.google.com/imgres?imgurl=http://img.medscape.com/pi/emed/ckb/radiology/336139-398308-1113.jpg&imgrefurl=http://emedicine.medscape.com/article/398308-overview&usg=__fG6ADJhsh0C53tKyKvpMvE2ai_A=&h=483&w=220&sz=52&hl=en&start=4&zoom=1&tbnid=Ei5zQBpM5umcyM:&tbnh=129&tbnw=59&ei=AneHTcyWOYXzrQePyvAs&prev=/images?q=distant+metastasis,+Technetium+whole+body+scan&hl=en&sa=G&gbv=2&tbs=isch:1&itbs=1http://www.google.com/imgres?imgurl=http://www.ispub.com/ispub/ijo/volume_5_number_2_37/extensive_metastases_from_gastric_adenocarcinoma_in_a_teen_male_presenting_as_anemia/gastric-fig2.jpg&imgrefurl=http://www.ispub.com/journal/the_internet_journal_of_oncology/volume_5_number_2_37/article_printable/extensive_metastases_from_gastric_adenocarcinoma_in_a_teen_male_presenting_as_anemia.html&usg=__mAd1DJF8ATvD46-sdPsUIBlQpFg=&h=260&w=427&sz=21&hl=en&start=4&zoom=1&tbnid=ecKqRcCoqTu7FM:&tbnh=77&tbnw=126&ei=rXGHTdmIFYyqrAeLqvks&prev=/images?q=metastasis,+liver,+USG&hl=en&sa=G&gbv=2&tbs=isch:1&itbs=1http://www.google.com/imgres?imgurl=http://www.e-radiography.net/technique/chest/cxreval20.jpg&imgrefurl=http://www.e-radiography.net/technique/chest/chest_eval.htm&usg=__TKrdSvBKwE-8H4slKbdxkBHW2rE=&h=451&w=446&sz=19&hl=en&start=1&zoom=1&tbnid=UvJ3sXC-lO_AEM:&tbnh=127&tbnw=126&ei=R3GHTYX3MMPqrAed3Pkt&prev=/images?q=coin+lesion,+chest+X-ray&hl=en&sa=G&gbv=2&tbs=isch:1&itbs=1


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STAGING ( TNM )

PREOPERATIVE


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INTRAOPERATIVE Suprahyoidal dissection ( for lip cancer )

Supraomohyoidal dissection ( for oral cancer )

Sentinel node biopsy ( for lip and oral cancer )

Radioisotope Blue dye


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T Staging for Tumors of the Lip and Oral Cavity

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor 2 cm or less in greatest dimension

T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension

T3 Tumor more than 4 cm in greatest dimension T4a

Lip Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth,or skin of face (ie, chin or nose)*

Oral Cavity Tumor invades through cortical bone, into deep [extrinsic] muscle oftongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary

sinus, or skin of face T4b Tumor involves masticator space, pterygoid plates, or skull base and/or

encases internal carotid artery


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N Staging for Tumors of the Lip and Oral Cavity

Nx Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatestdimension

N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not

more than 6 cm in greatest dimension; or in multiple ipsilaterallymph nodes, none more than 6 cm in greatest dimension; or inbilateral or contralateral lymph nodes, none more than 6 cm ingreatest dimension

N2a Metastasis in a single ipsilateral lymph node more than 3 cm but notmore than 6 cm in greatest dimension

N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cmin greatest dimension

N2c Metastasis in bilateral or contralateral lymph nodes, none more than6 cm in greatest dimension

N3 Metastasis in a lymph more than 6 cm in greatest dimension


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Stage Grouping

I : T1 N0 M0

II : T2 N0 M0

III : T3 N0 M0/ T1 N1 M0/ T2 N1 M0/ T3 N1 M0

IVA : T4a N0 M0/ T4a N1 M0/ T1 N2 M0/ T2 N2 M0/

T3 N2 M0/ T4a N2 M0

IVB : T4b Any N M0/ Any T N3 M0

IVC : Any T Any N M1


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SALIVARY GLAND CANCER

SALIVARY GLAND

MAJOR Parotid gland : malignancy 30%

Submandibular gland : malignancy 50%

Sublingual gland : malignancy 70%

MINOR Submucosal

upper aerodigestive tract : malignancy - > 90%


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PAROTID GLAND CANCER

SYMPTOM

EARLY

Mass in the posterior cheek region

LATE

Pain ( local, auditory canal )

Asymmetry of the face

Numbness of trigeminal nerve

Trismus

Dysphagia


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PHYSICAL EXAMINATION

Hard in consistency

Infiltration ( skin, soft tissue)

Facial nerve paresis

Intra oral : deviation of soft palate

Enlargement of cervical lymph node


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IMAGING

Signs of malignancy

Cervical lymphnodes metastasis

USG

CT scan


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TISSUE DIAGNOSIS

FNA

FROZEN SECTION

OPEN BIOPSY


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STAGING (TNM)


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T Staging for Parotid Tumors

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor 2 cm without extraparenchymal extension T2 Tumor >2-4 cm without extraparenchymal extension

T3 Tumor having extraparenchymal extension without 7th

nerve involvement and/or >4 cm

T4a Tumor invades skin, mandible, ear canal, and/or facial nerve

T4b Tumor invades skull base and/or pterygoid plates and/or

carotid artery


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N,M Staging for Parotid Tumors

N1 Metastasis in a single lymph node, 3 cm

N2 Metastasis in a single lymph node, 3-6 cm;

Multiple ipsilateral, bilateral or

contralateral lymph nodes 6 cm

N3 Metastasis in a lymph node >6 cm

M1 Distant metastasis


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Staging

I T1N0M0

II T2N0M0

III T3N0M0/ T1N1M0/ T2N1M0/

T3N1M0

IVA T4aN0M0/ T4aN1M0/ T1N2M0/

T2N2M0/ T3N2M0/ T4aN2M0

IVB T4bNM0/ Any T N3M0

IVC Any T any N M1


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>70% patients will present in late stage (III, IV)

OPERABILITY

TREATMENT MODALITIES

CHOICE OF TREATMENT

FOLLOW-UPPROGNOSIS


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MOST IMPORTANT

PREVENTION Say No to Tobacco and Alcohol

EARLY DETECTION Health education

Physical diagnosis

Toluidine blue

AVOID DOCTOR DELAY


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Documents

Head & Neck Cancer Diagnosis