Head-Neck Cancer/Malignancy

Cancers of the head and neck are the sixth most common cancers world wide, with an increasing frequency in developing countries.

Although there are a variety of histological types Squamous cell carcinoma is the commonest head neck cancer. One of the most important prognostic factors in head and neck cancer is the presence or absence , Level and size of metastatic neck disease. Many carcinomas with in the head or neck will sooner or later metastasise to lymph nodes and various factors control the natural history of this event. Cont

Once a neck node metastasis has occurred, further spread of the disease may not happen for many months or indeed years in conditions such as papillary carcinoma of the thyroid.

Anatomical division: Anterior triangle Posterior triangle

Fascial neck spaces: Superficial fascia Deep cervical fascia:

1.The investing or outer layer 2.The visceral or middle layer 3.The internal layer

Head and neck lymphatics:

About 600 lymph nodes in the body About 200-300 lymph in the head and neck region The lymphatc drainage of the head and neck is conventionally divided into three system.

a. Waldeyers internal ring b. Suprficial lymph node system Occipital, Postauricular, Parotid or Preauricular & buccal or facial nodes. Superficial cervical, submandibular, submental, anterior cervical nodes. c. Deep system (Cervical lymph nodes proper) Situated along the internal jugular vein, the spinal accessory group, visceral nodes in the midline.

Natural history and evolution of malignant disease in the neck (Lindberg 1972)

Site of metastasis in relation to primary site of tumor:

Level-I- Submental & Submandibular group Level-II- Upper jugular group-(carotid bifurcation) Level-III- Middle jugular group Carotid bifurcation
to cricoid cartilage where omohyoi muscle crosses the int. jugular vein.

Cont

Level-IV- Lower jugular group (Cricoid cartilage

to clavicle)

Level-V- Posterior triangle group Level-VI- Anterior compartment group (visceral

group)

Level-VII- Upper anterior mediastinum.

Clinical staging : UICC/AJC TNM classification

Differential diagnosis of a suspected malignant cervical node /Neck mass

Thyroid swelling =50% Nonthyroidal swelling = 50% Congenital and developmental = 24% Inflammatory = 6% Neoplastic = 70%

Cont

Primary neoplasm (Benign+Malignant) = 15% Secondary (Metastatic) = 85%

Congenital & developmental thyroglossal duct cyst, branchial cyst, dermoid cyst, cystic hygroma

Inflammatory:
Nonspecific cervical lymphadenitis Specific cervical lymphadenitis Tuberculosis, syphilis etc Actinomycosis, sarcoidosis, Salivary gland inflammation

Neoplastic lesions:

Primary thyroid tumors Salivary gland tumors

Tumors of neurogenic origin:

Neuroblastoma, Neurofibroma Miscellaneous : Lipoma, haemangioma, Sarcoma, carotid body tumor Lymphoma:commonest primary malignant neoplasm Metastatic 80-90% from head-neck region Remaining 10-20% from lungs, breast, GIT, testis, ovary

Incidence of tumour types:

1. Sq. cell carcinoma 2. Undifferentiated carcinoma 3. Adenocarcinoma 4. Melanoma 5. Leiomyosarcoma 6. Chondrosarcoma

Three points remember:

1. Persistent lump in adult in the neckmalignants 2. Malignant tumor in the neck metastatic 3. Most metastatic neck mass originated from primay sites in the head & neck region.

The following primary sites which should always be under suspicion as a source for a metastatic node in the cervical region. Nasopharynx Tonsil Base of tongue Hypopharynx (piriform fossa) Thyroid

Occult primary

Metastatic neck node with unknown primary tumor Incidence = 3-5%

Investigation

History Clinical examination Haematological Serological Tuberculin test FNAC Cont

Radiological X-ray chest X-ray PNS CT Scan MRI Ultrasound Contrast X-ray upper & lower GIT

Triple Endoscopy:

Laryngoscopy Oesophagoscopy Bronchoscopy

Examination of Nasopharynx Under G/A Blind biopsies Postnasal space Tonsils Tongue base Incisional biopsy - Lymphoma

Management
Aims of treatment: Curative treatment Palliative Salvage

Neck dissection- Radical neck dissection Functional neck dissection

Radiotherapy Chemotherapy Combined

Follow up: Midline neck swelling 1. Congenital & developmental - Thyroglossal cyst, Dermoid 2. Inflammatory Lymphadenitis - Acute - Chronic- Specific, Nonspecific 3. Enlarged lymphnode Lymphoma, Metastatic 4. Thyroid in origin 5. Miscellaneous Subhyoid bursa