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Overview Of Head &

Neck Cancer
By Dr Lim Poon Seong
ENT HPP
Definition
Tumour (Neoplasm) is a mass of tissue formed as a
result of abnormal, excessive and inappropriate
proliferation of cells.The growth will continues
indefinitely regardless of the mechanism which control
normal cell proliferation.

Benign- a single mass, localized, symptomless and


can be excised completely.

Malignant- invade surrounding tissues, spread by


lymphatic and blood vessels to other parts of body
Epidemiology
Top Cancers in Malaysia (Malaysia Cancer Statistic
2006)

Female Breast Cancer (3525)

Head & Neck Cancers (2884)

Colorectal (2866)

Lung Cancer (2048)


Type of Head & Neck
Cancer
Nasopharyngeal Cancer (981)

Thyroid Cancer (891)

Oral Cancer (428)

Laryngeal Cancer (216)

Salivary Gland Cancer (142)

Pharyngeal Cancer (113)

Sinonasal Cancer(113)
Risk Factors
Smoking

Alcohol

Tobacco and betel nut chewing

Early salted fish consumption

Wood dust exposure HPV in oropharyngeal cancers

Epstein Barr virus in nasopharyngeal cancers

Human Papilloma virus infection in oropharyngeal cancers


Histology
The spectrum of malignant tumours vary widely
and includes:

Surface epithelium

Squamous cell carcinoma over 90%

Malignant melanoma

Basal cell carcinoma

Glandular epithelium

Adenocarcinomas in females

Mucoepidermoid carcinomas in males

Adenoid cystic carcinoma

Acinic cell carcinoma

Mesenchymal tissues

Lymphomas, Sarcomas are very rare


Anatomy
Nasopharynx Anatomy

Extend from skull base


superiorly till soft palate
inferiorly

Eustachian tube

Torus Tubaris

Fossa of Rosenmuller
Oral Cavity Anatomy

Extend anteriorly from lip to


anterior pillar of tonsil
posteriorly

Subsites: Lip, buccal mucosa,


alveolar, floor of mouth, hard
palate, anterior 2/3rd of
tongue, retromolar trigone
Oropharynx/Hypopharynx
Anatomy
Oropharynx extends from level of
hard palate to hyoid bone inferiorly

Subsite: Uvula, soft palate,


tonsils, base of tongue,
vallecula and lingual surface if
epiglottis

Hypopharynx extend from floor of


the vallecula to inferior border of
cricoid

Subsite: Posterior pharyngeal


wall, pyriform fossa and post
cricoid
Larynx Anatomy
From the epiglottis to the
inferior cricoid cartilage

Vocal cords, piriform sinuses,


arytenoid cartilage and
aryepiglottic folds

Subsite: Supraglottis, glottis


and subglottis
Paranasal sinus anatomy

Paranasal sinuses are a group


of four paired air-filled spaces
that surround the nasal cavity

Subsite: Maxillary, ethmoid,


sphenoid, frontal sinus
Salivary gland Anatomy
Salivary gland secretes saliva
into oral cavity

Major salivary glands (Paired)

Parotid, submandibular,
sublingual

Minor salivary glands


(scattered over the upper
aerodigestive tract)
Cervical Lymph Nodes
from level of swelling, can
identify which part the cancer
spreads to
Spread Of Primary to Neck
Level of LNs Primary

Oral Cavity, nasal cavity, paranasal sinus, submandibular


Level I
gland

Level II Oral cavity, nasal cavity, parotid gland, oro/hypopharynx

Level III Larynx, oral cavity, oro/hypopharynx

Level IV Oesophagus, hypopharynx, larynx

Level V Nasopharynx, oropharynx

Level VI Larynx (glotis/subglotis), thyroid, pyriform sinus


usually the midline structure

typically spread to retropharyngeal lymph nodes first???


Nasopharyngeal Ca
Presentation
Most common symptom (Neck)- 60%

Insidious painless neck node, Juguladigastric (L2)/


Posterior triangle/ Supraclavicular progressively
increasing in size (NPC till proven otherwise)

Nasal 20-30%

Painless blood stained rhinorrhoea or blood stained


sputum on hawking

Nasal obstruction
Otological 10-20%

Unilateral conductive deafness more then 2 weeks


with no obvious reasons ie preceding URTI

With/ without tinnitus

Neurological 5-10%

Sudden onset diplopia VI nerve palsy (most


common)

Lower cranial nerve palsy pseudo-bulbar palsy


NPC usually spreads to neck early
Normally if spread to neck, the prognosis is not so good

Early Cases
Advanced Cases
NPC Classifications

WHO classifies NPC into 3 types:

Keratinizing SCC (type I)

Non-keratinizing SCC (type II)

Undifferentiated SCC (type III)


Prognosis: Nasopharnx

Keratinizing squamous cell carcinoma has a higher


risk of local recurrence after treatment than non-
keratinizing SCC or undifferentiated usually not so responsive to
radiotherapy treament

High EBV DNA titers after treatment are associated


with an increased risk of recurrence
Oral Cavity Ca Presentation

Most easily detected


any ulcer that lasts more than 2 weeks and non-healing
Commonly starts as ulcer must seek medical attention

Late presented as fungating mass

trismus

Neck swelling
Early Cases

tumour ulcer
Advanced Cases

must have high suspicion level and pick up early for better prognosis
Presentation: Oropharynx
Ca
posterior to oral cavity

Globus sensation

Difficultly swallowing

Slurred speech

Pain in throat or ear

trismus

Neck swelling
Hypopharynx Ca
Presentation
located at the oesophageal inlet so pt
will lost a lot of weight

Dysphagia

Pain

Referred otalgia

Hoarseness

Neck mass

Hemoptysis

Weight loss
rare for larynx Ca to spread for neck, hence if it does, prognosis is not so good

Presentation: Larynx Ca
cancer spread to paraglottic space --> vocal cord palsy
so when you speak, vocal cord cannot function properly
So got gap, when swallow, will get aspiration into
the lungs
Hoarse voice (most common)

Stridor

Cough, hx of GERD

Trouble swallowing

Neck swelling
General Management of
Head & Neck Ca Patient
Prevention and early diagnosis if cancer involves more subsites, prognosis is worse

Once suspected patient had malignancy, need to perform


comprehensive assessment (Complete history, PE,
Endoscopic assessment of upper aerodigestive tract0)

Perform complete examination to assess the primary


tumour site, neck examination and also systemic
examination to get the clinical TNM staging of the disease
CT --> see whether tumour has invaded into other structure like muscle

Imaging studies such as Ultrasound/CT/MRI to stage the


disease
CXR and ultrasound abdomen to look for distant
metastasis

Perform biopsy under LA/GA to confirm the


diagnosis

Base on the final staging of the disease, discuss


about treatment options with the patient

Generally 3 modalities of treatment

Radiotherapy, chemotherapy and surgery


Imaging Studies
Findings that lead to suspicion of
malignancy

Primary tumour- rim


enhancement, obliteration of
tissue planes

Neck- Enlargement of cervical


lymph nodes (Size >1cm, central
necrosis, loss perihilar fat plane)

Distant metastasis- lung or liver


nodule
Biopsy

Primary tumour- depends on accessibility (LA vs


GA)

Cervical lymph nodes- need to perform Fine


Needle Aspiration Cytology (FNAC) first. Should
avoid open biopsy, can cause upstaging of neck
because causes extra capsular spread
if involve vocal cord, must perform under GA because if not, will cause laryngeal spasm and subsequently stridor
unless it is a vascular swelling, else will perform FNAC first???
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
Staging
Staging of cancer: to have a standard comparison between 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
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 early Ca

TX Extend of primary tumour cannot be assessed post-surgery


wait for imaging study results
hence put Tx
Lymph node:

Is used to describe progressive lymph node involvement

N1 Single ipsilateral nodes 3 cm or less in diameter

N2 Single ipsilateral nodes more than 3 cm but less than 6 cm, or


multiple clinically positive ipsilateral less than 6 cm

N2a Single
N2c - Bilateral lymph nodes
N2b Multiple

N3 Clinically positive ipsilateral more than 6 cm, Bilateral or


contralateral

N3a ipsilateral more than 6 cm

N3b Bilateral, each side staged separately

N3c Contralateral only


Distant metastasis:

M0 No metastases present
Spread to lung and liver in
early cases and bone in late
M1 Metastases clinically demonstrable cases

MX Metastases cannot be assessed

TNM Staging: most important prognosis depends


on neck nodes involvement

Stage I: T1, N0, M0 1 and 2 early stage 1 and 2 only finger modality
3 early advanced as treatment eg surgery /
4 advanced radiotherapy
Stage II: T2, N0, M0 beyond that requires combined
modalities

Stage III: T3, N0, M0 or T1, 2 or 3, N1, M0

Stage IV: T4, N0 or 1, M0 or T1 4, N2 or 3, M0 or T1


4, N1 3, M1
Pre treatment
Assessment
Performance status(to quantify cancer patients
general well being and activities of daily life)

Important to determine whether the intensity of


chemotherapy treatment patient can receive

Common scoring system used ECOG or Karnofsky


ECOG (European Cooperative
Oncology Group) Scoring
Grade Condition of Patient
Asymptomatic (Fully active, able to carry on all pre disease
0
activities without restriction)
Symptomatic but completely ambulatory (restricted in
1 physically strenuous activity but ambulatory and able to carry
work of light or sedentary nature)
Symptomatic, <50% in bed during day (ambulatory and
2
capable of all self care but unable to carry out any work)
Symptomatic, >50% in bed, but not bed bound (capable of
3 only limited self care, confined to bed or chair >50% of waking
hours)
Bed bound (completely disabled, cannot carry on any self care
4
and totally confined to bed or chair

5 Death
preferably

Karnofsky Scoring
Score Perfomance Status
100 Normal, no complaints, no evidence of disease
90 Able to carry on normal activity with minimal sign/symptoms of disease
80 Normal activity with effort, some sign/symptoms of disease
70 Able of self care but unable to carry on normal activities/active work
60 Requires occasional assistance but is able to most personal self care
50 Requires considerable assistance and frequent medical care
40 Disabled, requires special care and assistance
30 Severely disabled,hospital admission indicated but death not imminent
20 Very sick,hospital admission necessary with active supporting Rx
10 Moribund, fatal processes progressing rapidly
0 Dead
Treatment Modalities
eg Ca larynx --> will need to remove larynx so will lose voice

Surgery: First choice when possible, but often


limited by disfigurement and preservation of organ
function such as speech and swallowing

Radiation: Most head and neck cancer is sensitive


to radiation while preserving organ function must ensure that stage 1
and 2 to use 1 modality
only to save other
treatments for later
Side effects can be severe; Mucositis, stages

permanent xerostomia, osteoradionecrosis of


the mandible, altered taste, weight loss, and
tooth decay
Chemotherapy: Can have dramatic response to
treatment, but is often not a durable response

Side effects can also be severe; decreased


blood counts, anemia, infections, weight loss,
nausea, vomiting, and hair loss

Newer targeted therapies have lower side


effects
Overview of Head & Neck
Cancer
Need to consider treatment for primary as well as neck

Stage I or Stage II disease- Single modality


treatment (surgery or radiotherapy)

Stage III disease- combine modality treatment


neoadjuvant - any chemo or radio before surgery
(surgery with postoperative adjuvant - any chemo or radio after surgery
radiotherapy/chemotherapy or radiotherapy
combine with chemotherapy- organ sparring
treatment protocol)

Stage IV disease- palliative treatment


NPC

Cancers of the oral cavity are generally treated by


primary surgical resection. Adjuvant radiotherapy or
concurrent chemoradiation is indicated for high risk group

Tumour of the pharynx (oropharynx/hypopharynx)


are treated primarily with combined chemoradiation
(Organ preservation protocol)

Laryngeal cancers are also treated with chemoradiation


if the larynx in functional. However, if the tumour has
or invade thyroid cartilage
destroyed the laryngeal skeleton, surgery may be
required to restore an adequate airway and maintain
swallowing.
Neck Dissection in Head &
Neck Ca

Selective neck dissection

Radical neck dissection open neck > remove all levels of neck nodes > remove SCM,
internal jugular vein, and spinal accessory nerve

Depends on the N staging of disease

modified radical neck dissection > remove all levels of neck nodes but retain other structures
Conclusion
usually will need plastic and skin team

Treating Head and Neck cancer need multidiciplinary team

Include Rehabilitation team speech therapist to restore voice after removal of larynx

Prognosis depends on stage on presentation

Major challenges are :

1. Delay in presentation , hence advanced stage tumour

2. Access to the tertiary facilities for investigations and


treatment

3. Alternative medicine
Early Ca Larynx treated With
Laser Surgery

tumour over vocal cord


advantage: preserve pt voice
Advanced Ca Larynx

stridor
tracheostomy
reconstruction

removal of larynx
Neck Dissection

removal of neck nodes preserve spinal accessory nerve


Radiotherapy Treatment
pt need to be on tx for 2 months
Thank You