Neoplasms of head and neck

Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
NEOPLASMS
OF
THE HEAD AND NECK
((Handouts))
(A lecture for Final year Medical Students)
By
Khairy Alhag Abu Shara M.D.
Senior consultant ENT and Head &Neck surgeon
Ex-Chairman of ENT Medical council 99-06
MOH - Kuwait
2010-2011
ART
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
Total laryngectomy
Cancer tongue
Angiofibroma
Carotid body tumour
Post-cricoid carcinoma
Cancer palate
Ear Haemangioma
Acoustic neuroma
(From Author's collection, copy write protected.)
A neoplasm or a tumor is a self controlling growth of unlimited multiplication of abnormally in
shape and pattern cells in a tissue or an organ, the growth is unlimited, it is functionless in
controversy to hyperplasia. It is either benign or malignant.
A benign tumor is usually small, well capsulated, solid or cystic. Microscopically the cells
resemble the same type and pattern of tissue origin (differentiation). It grows slowly by
expansion with pressure on the surroundings which may cause symptoms, it doesn’t spread
and it doesn’t destroy. It wil not recur if completely excied.
Some of benign tumours may transform to malignant and this will be suspected by increase in
growth rate, loss of differentiation with histopathology evidence and the tumour starts to
infiltrate.
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
A malignant tumour usually reaches large size in short time; it is a hard fixed irregular mass
with il defined edges. It is either fungating, ulcerative or infiltrating.
They are non capsulated, usually shows necrosis and haemorrhage, there is loss of
differentiation and according to the degree of similarity they are differentiated into well,
moderate and non differentiated or anaplastic histologic types, cells shows pleomorphism,
hyperchromatism, mitotic figures and tumour giant cells. Also there is loss of polarity. Growth is
rapid, infiltrative, send regional and distant metastasis. It is a killing disease, usually it gets
tendency of recurrence
There are non neoplastic BUT neoplasm like conditions e.g. cysts or polypi. The title of
masses or lumps will include altogether.
NECK LUMPS
A- In Children
80 % benign, it is either
[1] Inflammatory: in most of cases secondary to tonsillitis, dental infection, or associated with
exanthemata.
[2] Congenital: thyroglossal cyst, branchial cyst, dermoid, cystic hygroma, etc....
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I
single node region or one extra lymphatic organ
II
more than one region on one side of the diaphragm
III
on both sides of the diaphragm
IV
diffuse involvement
B
associated fever, loss of weight, etc....
A
no associated symptoms
It is normal in children to have easily palpable neck nodes
B- In Adults
80 % malignant, most of which are metastasis from head & neck, lungs, breast, stomach,
pancreas, kidneys, prostate, or uterus
The benign : non specific inflammatory Nodes, infectious mononucleosis, T.B and HIV,
salivary tumors , thyroid tumors, Sjogren’s syndrome, sarcoidosis , laryngoceles,
pharyngeal pouch.
Cervical lymph nodes
The neck includes 300 lymph nodes, 150 on each side
It is distributed in various neck triangles
Outer ring: submental, submandibular, pre-auricular, post-auricular and occipital
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
Midline anterior group
Upper and lower deep cervical groups
Posterior triangle group.
It could be involved in secondary malignant condition with an evident primary
Sometimes, the malignant nodes shows in neck nodes first, while the primary is
To be fetched for (What we call Occult Primary)
Some normal structures might be misdiagnosed as neck nodes e.g.
o Lateral process of axis
o Calcified carotid bulb
o Styloid process
o Cervical rib
OCCULT PRIMARY
Secondaries could be the first presentation in cancer head and neck
60% from nasopharynx
20% from oropharynx: tonsils, base of tongue, vallecula.
10% from pyriform fossa
10%: melanoma, thyroid, bronchus, breast, stomach
1/3 of cases primary diagnosed at presentation time, another 1/3 wil show by follow up
INVESTIGATIONS
CBC, ESR.
ENT evaluation and upper pan-endoscopy with multiple biopsies
X-ray lateral neck, sinuses chest x-ray
Tests for T.B., HIV, sarcoidosis, monospot test
Thyroid scan
FNAC
Cancer needs an international language for data transfer between centers and a unique
classification to follow up the progress or regress of malignant tumors and there staging
to understand its behavior and the prognosis. The most popular classification is the
TNM which was designed by the UICC-France.
The T stands for Tumor and it is different from an area or an organ to another.
While the N and M are constant and stands for Lymph Nodes and Distant metastasis
respectively.
TNM
NECK NODES
NX
no satisfactory assessment
N0
non
N1
single epsilateral less 3 cm
N2a
single epsilateral 3-6 cm
N2b
multiple epsilateral 3-6 cm
N2c
contra or bilateral 3-6 cm
N3
more than 6 cm
TNM
DISTANT METASTASES
MX no satisfactory assessment
M0 non
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
M1 distant metastases
[PUL-OSS-HEP-BRA-Non Regional LYM-MAR-PLE-PER-SKI]
PITFALLS OF TNM CLASSIFICATION
It takes in consideration the surface only which could be the tip of an iceberg, this is
corrected by adding certainty factor (c):1 to 5
1: Standered
2: CT, MRI, FNAC, lymphangiography.
3:Surgical.exploration
4: Resected specimen
5: Autopsy
It ignores the immunological condition of the patient
CANCER IS
A HISTOPATHOLOGICAL DIAGNOSIS
THE NOSE AND SINUSES: Anatomy
• The nasal cavity is divided into two by the nasal septum which forms the medial wall, anteriorly the
vestibule of the nose, posteriorly the choanae, above is the cribriform plate, below is the palate,
laterally the turbinates and the meati where the paranasal sinuses open.
• Maxillary Sinuses:
– Pyramidal
– 15 ml
– Rudimentary at birth developed at 12 years
– Grow with teeth eruption
– Relations: Eye, teeth, face, Ptyrigo-palatine fossa, zygoma and middle meatus
– Ostium: At Ancenet-Bulla angle
• Frontal Sinuses:
– Between inner and outer table of frontal bone behind super-ciliary arches
– Irregular asymmetrical pyramid
– 7 ml
– Absent at birth develops at 8 years
– Relations: Skin, Anterior Cranial fossa, Olfactory nerve, orbit
– Ostium: antro-medial aspect of floor down to infundibulum through naso-frontal duct
• Ethmoidal Sinuses:
– Ethmoidal labyrinth
– 7 ml
– Small at birth and grow rapidly till 8 years
– 2 groups of variable size air cells with grand lamella in-between
– Relations: Orbit( the lateral wall of Bulla ethmoidalis is nothing but lamina papyrsia), Optic nerve,
Ant. Cranial fossa , nasal cavity, sphenoid, maxilla, lacrimal sac
– Extensions: Agar nasi, concha bullosa, Onodi cells
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
• Sphenoidal Sinuses
– Within body of sphenoid
– 1 or 2 asymmetrical
– 7 ml
– Small at birth and fully developed at pubirty
– Variations of pneumatization:
• Non
• Pre-sphenoidal: till ant. Bony wall of pituitary fossa
• Post-sphenoidal: extends below pituitary
• Occipital: to basilar part of occipital bone
– Laterally:
• Cavernous sinus, optic nerve, superior orbital fissure
– Superiorly
• Pituitary gland, optic chiasma, olfactory tract, Frontal brain lobe
– Inferiorly
• Roof of nasal cavity and nasopharynx, Vidian and maxillary nerves and branches of spheno-palatine ganglion
– Posteriorly:
• Pons and basilar artery
– Anteriorly:
• ethmoids
•Roof of nasal cavity and nasopharynx, Vidian and maxillary nerves and branches of spheno-palatine ganglion
–Posteriorly:
•Pons and basilar artery
–Anteriorly:
•ethmoids
THE NOSE AND SINUSES: Tumors
Benign: papil oma, osteoma, angioma, chondroma, fibroma.
Locally malignant: adamantinoma, osteoclastoma.
Malignant:carcinoma: in males above 40, while sarcomas occur in children.
Med line lethal granuloma is nothing but a T- cell lymphoma
MALIGNANCY
Etiology:
o Nickel dust, hardwood dust, mustard gas, radiation, snuff.
o Pre-cancerous disease: inverted papilloma
Symptoms: unilateral epistaxis, foul nasal discharge, trismus , unilateral nasal
obstruction , unilateral epiphora- proptosis -loss of teeth -cheek swelling -
pain ( 2nd
division of trigeminal)
Signs
Ant. Rhinoscopy: friable ulcerated mass, bleeding on touch.
Cervical node -late- : (skin)
Cachexia: late
Investigations: CT, MRI, biopsy.
Treatment:
Surgical
Irradiation
Chemotherapy
CANCER MAXILLA
TNM
T1
Antral mucosa
T2
Infrastructure destruction
T3
Skin, post wall of maxilla anterior ethmoids, medial orbital wall
T4
Orbit, nasopharynx, sphenoid or dura
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
CANCER ETHMOIDS
TNM
T1
Confined to ethmoids
T2
Extends to nasal cavity
T3
Extends to anterior orbit, and or maxillary sinus
T4
Intracranial extension, orbit, sphenoid, frontal or nasal skin
THE NASOPHARYNX: ANATOMY
It is a cubical space 2.5x2.5x1 cm
In front of first cervical vertebra (Atlas)
Floor = Soft palate
Anteriorly = Choanae 14X12 mm
Roof and posterior wall form a curve which lie under the body of sphenoid and basilar part of
occipitl bone
Laterally:
The pharyngo-tympanic tubes at the level of inferior turbinate
Torus tuberialis
Pharyngeal recess
It is connected to the oropharynx through the palato-pharyngeal isthmus which has the
following boundaries:
Posterior pharyngeal wall
Posterior wall of soft palate
NASOPH. ANGIOFIBROMA
Very vascular, from periosteum, starts at puberty.
Symptoms: nasal obstruction, sever rec. epistaxis., proptosis (late), cheek and zygomatic
oedema (late), eust. obst
Signs: ant & post. rhinoscopy,hard, lobulated, easy bleeding mass
investigations: MRI, C.T, angiography
Treatment:surgical:transpalatal or moure’s lateral rhinotomy.
TCVO
Deep x-ray
Types:
Type 1:
nasopharynx & nasal cavity
Type 2:
invade ptyrigopalatine fossa, maxilla, and ethmoids with bony
destruction
Type 3a:
infratemporal fossa, and orbit
Type 3b:
infratemporal fossa, and para sellar extension.
Type 4a: intracranial
Type 4b:
intracranial with infiltration of cavernous sinus, pituitary fossa or optic chiasma
NASOPHARYNGEAL CARCINOMA
Usually in old age
Oetiology: EPV, salted fish
Presentation: nasal, aural, neural for last 4 cranials, neck nodes.
Posterior rhinoscopy: mass or ulcer
C.T scan (bone) & MRI (soft tissue)
EUA PNS & biopsy
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
TTT by irradiation.
TNM
NASOPHARYNGEAL CARCINOMA
Tx
T0
Tis
T1
Confined to nasopharynx
T2
Extends to oro-pharynx or nose
T2a or T2b depends on para-pharyngeal involvement
T3
INVADED Sinuses or bone
T4
Intra-cranial extension or involvement of intra-cranial nerves or infra- temporal fossa or orbit
SALIVARY GLAND: Anatomy
· There are 3 paired major salivary glands: Parotids, sub-mandibular and sublingual
· There are about 400 minor salivary glands situated along the upper respiratory tract.
SALIVARY GLAND: TUMOURS
Benign:
pleomorphic adenoma
Monomorphic adenoma
Warthin’s tumour
Midway: mucoepidermoid tumour
Malignant: adenoid cystic ca., pleomorphic adenoma, sq cell ca., non Hodgkin’s
lymphoma.
SALIVARY GLAND: TNM
Tx
T0
Tis
T1
< 2cm without extra-parenchymal extension
T2
2 – 4 cm without extra-parenchymal extension
T3
< 6 cm with extra-parenchymal extension but facial nerve intact
T4
> 6 cm, invade facial nerve or skull base
THE ORAL CAVITY: Anatomy
It is fil ed by tongue and bounded by teeth
The tongue is a muscular organ covered by mucosa
The oral cavity is subdivided into:
· Vestibule: between teeth & gums and lips & cheeks.
· Oral cavity proper:
Roof=soft and hard palate
Floor=Mucosa, Frenulum lingulae, deep lingual veins,
Warton’s duct openings, sublingual papil ae and minor
salivary glands
Ant and lat=Teeth
Post= It communicates to oropharynx through oropharyngeal
isthmus: soft palat-dorsum of tongue-palatoglossus
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
THE ORAL CAVITY: TUMOURS
Etiology: alcohol, tobacco, bad dental hygiene
50% tongue, 15% buccal mucosa, 15% floor of mouth, 15% lower alveolus, 5% upper
alveolus
Ca tongue: painless ulcer, neck nodes in 1/3, TTT excision + radiation.
Ca floor of mouth: invade mandible, odynophagia & referred otalgia, TTT excision and
mandible reconstruction, and radical neck dissection, irradiation
OROPHARYNX: ANATOMY
Behind mouth and tongue
Below raised soft palate
Above epiglottis
In Front of 2nd and 3rd cervical vertebra
Connected to oral cavity through the oro-pharyngeal isthmus which has the following
boundaries:
Soft palate (above)
Dorsum of tongue (below)
Palato glossal arches (On each side)
OROPHARYNX : TUMOURS
Interfere with feeding and speech, presents as lump in the throat, 40% presents with lymph
nodes.
Benign: papil oma, mixed salivary tumors (painless)
Malignant: sq cell carcinoma 75 % appear as an ulcer, while sarcoma appears as a mass.
50% in tonsils, 20% tongue, 20% post. Pharyngeal wall, 10%soft palate and uvula
OROPHARYNX, OROAL CAVITY & LIP: TNM
Tx
T0
Tis
T1
Less than 2 cm
T2
2 - 4 cm
T3
More than 4 cm
T4
Invading adjacent structures
HYPOPHARYNX: ANATOMY
Post cricoid space:
from arytenoids to lower border of cricoid (c6)
Pyriform fossae:
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Neoplasms of the Head and Neck
Khairy Alhag Abu Shara M.D.
from pharyngo-epiglottic fold to upper end of esophagus, bounded laterally by thyroid
cartilage, medially by aryepiglottic folds, arytenoids, and cricoid cartilage
Post pharyngeal wall : from floor of vallecula to cricoarytenoid joint
HYPOPHARYNX : investigations
Ba. Swallow endoscopy and chest x-ray.
1/3 of patients are untreatable
Ca. Pyriform 60% : neck nodes occur before dysphagia
Ca. Post cricoid 30% :progressive dysphagia to solids, wt loss, neck nodes, Moure’s sign,
(Paterson-Brown-Kelly or Plummer-Vinson) is a pre-cancerous
Ca. Post. Pharyngeal wall 10% :
TTT: pharyngolaryngectomy + block neck dissection, irradiation.
CANCER HYPOPHARYNX: TNM
Tx
T0
Tis
T1
One subsite or less than 2 cm
T2
Two subsites or 2-4 cm
T3
Fixed cord or more than 4 cm
T4
Invaded cartilage
LARYNGEAL TUMOURS: Anatomy
The larynx is the organ of voice
It also gives an airway and fixation of the chest when an abdominal effort is needed
It is sub-divided into:
o Supraglottis
o Glottis
o Subglottis
LARYNGEAL TUMOURS
Benign
o Papil oma: single & multiple
o Haemangioma
o Chondroma
Maignant:
o Squamous cell ca
o Adenocarcinoma
o Adenoid cystic carcinoma
o Sarcoma
o Lymphoma
o Virrocus carcinoma:irrad
o Rhabdomyosarcoma
Pre-Cancerous lesions
Single papilloma in adults
Leucoplakea
CANCER LARYNX
Males to females 10: 1
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