Basic knowledge for 5th year medical students

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

20. Hypopharyngeal carcinoma
Investigations
EUA and biopsy
Panendoscopy
CXR
CT neck and chest
TFT
Staging is TNM
20

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

26. Tumors of the neck
LN groups
26

27. Tumors of the neck
Benign lesions:
Congenital
Branchial cyst
Thyroglossal cyst
Thymic cyst
Dermoid cyst
Hemangioma
Lymphangioma (cystic hygroma)
Acquired
Ranula
Laryngocele
Pharyngeal pouch
27

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.

31. Thyroglossal cyst
31
Differential diagnosis:
1.Congenital dermoid cyst
2.Sebaceous cyst
3.Enlarged LN
4.Subhyoid bursa
5.Pyramidal lobe of thyroid
6.Thyroid nodule
Complications
Infection
Thyroglossal sinus

32. Thyroglossal cyst
32
Treatment:
USG of the neck (Why?)
TFT
+/- FNAC
Surgical excision (Sistrunk’s operation)

33. Thyroglossal cyst
02/12/16

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

36. 02/12/16

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

39. 02/12/16

40. Salivary glands
Consists of:
Parotid gland
Submandibular glands
Sublingual glands
20-80 minor glands
40

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

42. Salivary glands tumors,
classification
1. Adenomas
 Pleomorphic
 Adenolymphoma
 Myoepithelial
 Basal cell
adenoma
 Ductal papilloma
 Cystadenoma
42
2. Carcinomas
 Acinic cell
 Mucoepidermoid
 Adenoid cystic
 Carcinoma ex-
pleomorphic
adenoma
 SCC
 Undifferentiated
3. Non-epithelial tumors
 Hemangioma
 Lymphangioma
 Lipoma
 Neural
4. Malignant Lymphoma
5. Secondary tumors
6. Unclassified tumors
7. Tumor-like conditions
 Sialometaplasia
 Sialoadenitis

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

49. 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

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.

51. Radiation therapy
51
Post-operative, indications:
Residual disease
Extra-capsular spread of LN
High grade tumors
Recurrence
Adenoid cystic tumors
Peri-neural disease
Palliative Radiotherapy
Non operable cases

52. Neurovascular and Soft Tissue
Neoplasms
52
Neurovascular
neoplasms:
1.Carotid body tumors
2.Schwannomas
3.Neurofibromas
4.Paragangliomas
Soft tissue neoplasms:
1.Lipomas
2.Fibrosarcomas
3.Rhabdomyosarcomas
4.Malignant fibrous
histiocytomas
5.Dermatofibrosarcoma
protuberans
6.Osteogenic sarcomas
7.Leiomyosarcomas.

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.

54. Carotid body tumor
54

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

56. Thank you
02/12/16
Time toTime to
wake upwake up
……