diagnosis and treatment options in head and neck neoplasms evan s. bates, m.d. dept. of...
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DIAGNOSIS AND TREATMENT OPTIONS IN
HEAD AND NECK NEOPLASMSEVAN S. BATES, M.D.
DEPT. OF OTOLARYNGOLOGY
NASAL/SINUS TUMORSOverall incidence: 1:100,000
80% SCCA, 10% ACC/ACRisk factors: environmental exposure
DiagnosisCT/MRI, biopsy
TreatmentSurgical resectionChemotx/XRT
This 37 yo male presented with a 4-5 week H/O an enlarging left neck mass. 3 months earlier he noted episodes of left nasal congestion with eye discomfort.
PMH: ASD repair 3/96
H/O smoking 1ppd/15 yr., quit 5 yr. go
Exam:
nasal: polypoid mucosa left inf.turbinate
oropharynx: nl.
neck: 6 x 5 cm firm, mid. Cervical mass
CASE PRESENTATION
EVALUATIONFNAB:
+ for malignant cells immunostain profile suggests medullary CA
MRI: large left neck mass, adenopathy in levels 2-4, small
left intraparotid masses. Thyroid nl.CXR: nl.Laboratory:
calcitonin 2, CEA <0.7, TSH, LFT’s nl.
DIFFERENTIAL DIAGNOSISLymphomaPrimary salivary neoplasm
mucoepidermoid CA, squamous CA, adenoCA
Thyroid neoplasmanaplastic CA, medullary CA
Sinus neoplasmsquamous CA, adenoCA
Unknown Head & Neck Primary
SURGICAL MANAGEMENT
Left radical neck dissection
Left total parotidectomy
SURGICAL FINDINGSNormal thyroid glandMultiple parotid cystsLarge left neck mass w/ additional
adenopathyFrozen section
c/w malignant neoplasmPermanent section
c/w rhabdomyosarcoma, alveolar type
SURGICAL MANAGEMENTLeft endoscopic turbinectomy, resection
of nasal massfindings
large polypoid mass on posterior inf. Turbinate with extension superiorly along lateral nasal wall to middle meatus
pathrhabdomyosarcoma
RHABDOMYOSARCOMA: MD ANDERSON EXPERIENCE
5 yr. Survival 44%, 60% w/combined TX.Poor survival
adult onset of diseasealveolar histology-distant mets
Symptoms:nasal obstruction (60%), facial pain (41%), facial
swelling (38%), proptosis (35%), epistaxis (27%)
RHABDOMYOSARCOMA: UCLA EXPERIENCE
Orbit (35%), Maxillary sinus (15%)35% had CNS extension from sinus/orbitHistology not a factor in prognosisOverall survival 34%Trend toward conventional surgery
followed by intensive chemo/XRT
RHABDOMYOSARCOMAMost common head&neck tumor in children,
rare in adults69% advanced @ presentation (Group III,IV)Ethmoid sinus most common site (46%)Nodal mets (46%), systemic mets(26%)Management: chemo/XRT/surgery7.6% 5 yr. survival
NOSE EXAMINATION
Usually seen in chronic sinusitis or chronic allergy patients
Topical corticosteroids of minimal benefit
Polyps require sugical excision and biopsy followed by long term allergy management
NASAL POLYPS
OROPHARYNGEAL CARCINOMA
Usually presents with painful oral ulcerAdult males 50-70 yrs. old
Risk factors: smoking, ETOHMajority of tumors SCCA, lymphomaManagement:
Surgery/XRTXRT/CHemotx
TONSILLAR CARCINOMA20-30% present with neck metastasesEvaluation with CT/MRI, Chest CT, PET scan,
LFT’sManagement must include neck diseaseStage I survival 80-90%, Stage IV survival 25-
40%Treatment standard involves surgery/XRT
TONGUE NEOPLASMS3% of all CA in US, 50% of CA in India,
3rd most common malignancy in France>90% SCCA, associated with tobacco
use, ETOHSurvival rate decreased with lymphatic
involvementTreatment focused on surgery/XRTReconstruction of prime importance
TONGUE CARCINOMATongue lesions can be resected primarily
due to tongue redundancyPrimary closure vs. local flapXRT for incomplete resection, T2 or
greater lesions or nodal disease
TONGUE MASSNeurofibromaMucosal covered mass rather than
ulcerated lesionSurgical resection alone is sufficient
NECK EXAMINATION
NECK MASSES KEY TO DIAGNOSIS IS HISTORY
TIME COURSE OF MASS PAINFUL/TENDER RECENT
INFECTIONS/TRAUMA SMOKER?
PHYSICAL EXAM LOCATION OF MASS FIRM/CYSTIC/TENDER/
MULTIPLE MASSES
NECK MASSES IF YOU SUSPECT INFECTION,
TREAT WITH 1 COURSE OF ANTIBIOTICS
IF NO RESOLUTION, REFER TO ENT EVALUATION
HEAD & NECK EXAM FNA-B CT/MRI
NECK EXAMINATION
Large thyroid mass suspicious for malignancy
FNA-B important Surgical resection with
CN X monitor Post-operative therapy
dependent on path
THYROID MASS
Uncommon site for oral carcinoma
Usually managed with wide local excision
Frequently seen in pipe smokers
LIP CARCINOMA
HOARSENESS MANAGEMENT:
REFER TO ENT IF PROLONGED OR DIAGNOSIS UNCERTAIN
INDIRECT LARYNGOSCOPY
BE SUSPICIOUS OF MALIGNANCY IN SMOKERS AT ANY AGE
Usually seen in smokers
Extremely hoarse voice for several weeks
May have referred otalgia
Obviously needs laryngoscopy/biopsy
LARYNGEAL CARCINOMA
LARYNGEAL CARCINOMATreatment goals shifted to larynx preservation
based on 1992 VA study11,000 new cases annually, >90% have
smoking exposure Induction chemotx/XRT preserves larynx in
64% patientsXRT for T1/T2 lesions5 yr. Survival 70-80% for T3< lesions, 40% for
T4 lesions
LARYNX EVALUATION
Usually a gravelly/hoarse voice History of voice
overuse/singers Voice rest may help Often associated with GERD ENT eval. for laryngoscopy
VOCAL CORD NODULE
HOARSENESS ASSOCIATED WITH URI
SELF-LIMITED RESOLVES IN 7-21 DAYS PROLONGED RESOLUTION IN
SMOKERS MANAGEMENT
ANTIBIOTICS (S. AUREUS) HUMIDIFICATION STEROIDS
HOARSENESS CHRONIC HOARSENESS
VOCAL OVERUSE VOCAL FOLD POLYPS GERD PRESBYLARYNGIS
ACUTE HOARSENESS IF ASSOCIATED WITH NECK
TRAUMA--ER
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