Tumours of the head

and neck
 Introduction

• Head 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 curative
 Introduction
• 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 incurable
 Introduction
• 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 cancer
 Introduction
• 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 rare
 Introduction
Surface Epithelium
1- Squamous cell Carcinoma
• Undifferentiated carcinoma
• Differentiated carcinoma
• Adenoid squamous
carcinoma
• Verrucous carcinoma
2- Basal cell carcinoma
3- Malignant Melanoma
 Introduction
Glandular epithelium
1- Adenocarcinoma
2- Mucoepidermoid
carcinoma
3- Adenoid cystic
carcinoma
4- Acinic cell carcinoma
5- Undifferentiated
carcinoma
 Introduction
Mesenchymal tissues
1. Sarcoma
• Fibrosarcoma
• Rhadomyosarcoma
• Osteogenic sarcoma
• Chondrosarcoma
• Neurogenic sarcoma
• Angiosarcoma
• Synovial cell sarcoma
2. Hodgkin’s & non-Hodgkin’s
lymphomas
3. Plasmacytoma & multiple
myeloma
4. Leukaemia
Metastatic carcinoma, sarcoma
 Introduction
• 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 transfusion
 Introduction
• 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 user
 Introduction 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 virus
 Introduction
• Acquired capability of cancer cell:
• Limitless replicative potential
• Evading apoptosis
• Self-sufficiency in growth signal
• Insensitive to antigrowth signals
• Sustained angiogenesis
• Tissue invasion and metastasis
 Assessment
• 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 treatable
 Assessment
• 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 treated
 Assessment
• 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 modality
 Assessment
• 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
examination
 Assessment
• The patient general condition:
• Assessed with full investigation and classified for
performance status
1. Grade 0 Fully active without restriction
2. Grade 1 Ambulatory but restricted in physically
strenuous activity
3. Grade 2 Ambulatory but unable to carry out any
work activity
4. Grade 3 Confined to bed but capable of limited
self care
5. Grade 4 Confined to bed and unable to carry out any
self care
Karnofsky Status
 Assessment
• 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
 Assessment
• 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 metastasis
 Staging
• 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
• TX – Extend of primary tumour cannot be assessed
 Staging
• Lymph node:
• Is used to describe progressive lymph node
involvement
• N1 – Single epsilateral nodes 3 cm or less in diameter
• N2 – Single epsilateral nodes more than 3 cm but less than 6
cm, or multiple clinically positive epsilateral less than 6 cm
• N2a – Single
• N2b – Multiple
• N3 – Clinically positive epsilateral more than 6 cm, Bilateral
or contralateral
• N3a – Epsilateral more than 6 cm
• N3b – Bilateral, each side staged separately
• N3c – Contralateral only
 Staging
• Distant metastasis:

• M0 – No metastases present

• M1 – Metastases clinically demonstrable

• MX – Metastases cannot be assessed

 Staging
• TNM Staging:
• Stage I: T1, N0, M0
• Stage II: T2, N0, M0
• Stage III: T3, N0, M0
T1, 2 or 3, N1, M0
• Stage IV: T4, N0 or 1, M0
T1 – 4, N2 or 3, M0
T 1 – 4, N 1 – 3 , M1
AJCC 1983
 Staging
• 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 intervention
 Surgical 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 disease
 Surgical 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 nodes
 Surgical 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 chain
 Surgical 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 margin
 Surgical 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 type
 Surgical anatomy The tongue
• Lymph drainage:
• Tip of the tongue:
• To the submental lymph nodes – to the
lower deep cervical chains
• The anterior 2/3:
• the lower deep cervical chains – jugulo-
omohyoid nodes
• Suprahyoid block dissection of no value
• The posterior 1/3:
• drain to the upper deep cervical chains
• The tip and middle part of the tongue
have rich bilateral capillary network
but less in the lateral margins
• The U-shaped floor of the mouth drain
to the submandibular lymph nodes
• Bilateral drainage from the anterior
part of the U
 Surgical 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 nodes
Surgical 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 area
 Surgical 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 cavity
 Surgical 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
nodes
 Surgical anatomy
• The hard palate:
• Common location for carcinoma
of the minor salivary gland
• Presented as smooth, rounded,
bulging masses
• Squamous cell carcinomas
present as ulcerative or
exophytic lesion
• Invade the bone at an early
stage
• Involve the nasal cavity and the
antrum
• Metastases to submandibular
and upper deep cervical chains
• Disease of the elderly (60 – 70
years)
• More commoner in men
 Surgical 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 nerves
 Surgical 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 factor
 Surgical anatomy The maxillary sinus
• Classification
• T1 - confined to the mucosa of the infrastructure
• T2 - 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
muscle
• T4 – 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 nerves
 Diagnostic 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
lesion
 Diagnostic Techniques
• Toluidine blue vital
staining:
• Acidophilic metachromatic
nuclear stain that colors
sites of squamous cell
carcinoma but not adjacent
normal mucosa surfaces

• 1 – 2% applied to dry
surfaces and the dye diffuse
into tissue through the large
intercellular canaliculi
 Diagnostic 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
treatment
 Surgical anatomy
• Radiography:
• Routine X-Ray studies:
• Useful in cases of bony involvement
• Panoramic views shows lytic lesions
• Lateral soft-tissue films shows the extend into the nasopharynx or
hypopharynx
• Angiography:
• Define oral malignancy – mainly avascular
• Shows the relation to major vessels prior to surgery
• Selective transcatheter embolization for bleeding control or
decreasing tumor vascularity preoperatively
 Diagnostic 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 tumors
 Diagnostic 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
 Diagnostic Techniques
• Salivary gland scanning:
• I.V. Technetium shows an increased uptake in papillary
cystadenoma.
• Might occur with other benign or malignant tumors as a
focal areas
• Gallium-67 scanning:
• Gallium isotopes concentrate in a rapidly growing tumors
• Best in epidermoid carcinomas and lymphomas
• Used in lymphoma staging
 Diagnostic Techniques
• Tumor markers:
• Tumor markers are molecules occurring in blood or
tissue that are associated with cancer and whose
measurement or identification is useful in patient
diagnosis or clinical management.
• Tumor markers are most useful for monitoring
response to therapy and detecting early relapse
• They are generally products of the cancer cell, although
none is unique to cancer cells; they represent aberrant
tumor production of a normal element
 Diagnostic Techniques
• Tumor markers can be used for one of four
purposes:
• 1- screening a healthy population or a high risk
population for the presence of cancer
• 2- making a diagnosis of cancer or of a specific type
of cancer
• 3- determining the prognosis in a patient
• 4- monitoring the course in a patient in remission or
while receiving surgery, radiation, or chemotherapy.
 Diagnostic Techniques
• Carcinoembryonic Antigen “CEA”
• The CEA was one of the first oncofetal antigens to be
described and exploited clinically.
• It is a complex glycoprotein and is associated with the
plasma membrane of tumor cells, from which it may be
released into the blood.
• The primary use of CEA is in monitoring colorectal
cancer, especially when the disease has spread and to
check recurrence
• Other cancers produce elevated levels of this tumor
marker, including lymphoma, head and neck cancer and
cancers of the breast, lung, pancreas