Jesus E. Medina, M.D.
Head and Neck Neoplasms
Jesus E. Medina MD
Department of Otorhinolaryngology
The University of Oklahoma
Health Sciences Center
2015
Head and Neck Neoplasms?
● Lips
● Gingiva
● Tongue
● Floor of Mouth
● Buccal mucosa
● Palate
● Nasal fossa
● Paranasal sinuses
● Nasopharynx
● Oropharynx
● Hypopharynx
● Larynx
● Cervical esophagus
● Cervical trachea
Oral Cancer Histology
Minor Salivary Gland
Squamous Cell Carcinoma
92%
Melanoma
Sarcoma
Lymphoma
Head & Neck Neoplasms
Squamous Cell Carcinoma
● Annual incidence rate of 17/100,000.
● 5% of the 660,000 new cancers.
Head and Neck Neoplasms
● Major salivary glands
● Thyroid gland
● Parathyroids
● Ear and Temporal
Bone
● Skin of the Head &
Neck
● Melanoma
Head and Neck Cancer:
Survival According to Stage
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Stage I Stage II Stage III Stage IV
86%
26%
Head & Neck Neoplasms:
Delays in Diagnosis and Treatment
First Symptom or
Change Noted by
the Patient
TREATMENT
Head & Neck Neoplasms:
Delays in Diagnosis and Treatment
First Symptom or
Change Noted by
the Patient
TREATMENT
Diagnosis
First
Suspected
Referral
*
*ADVOCACY
Head & Neck Neoplasms
First Symptom or
Change Noted by
the Patient
TREATMENT
Diagnosis
First
Suspected
ReferralADVOCACY
Most delays in diagnosis
and treatment are due to
not knowing or ignoring
“THE BASICS”
Head & Neck Neoplasms
OBJECTIVES:
● To give you “the basic” information necessary for the
early detection and appropriate initial management of
H&N neoplasms.
● To familiarize you with the etiology/ risk factors,
symptoms and signs of these neoplasms.
Head and Neck Neoplasms
BEST
PROGNOSIS
IDEAL
TREATMENT
● EARLY DETECTION
● A systematic diagnostic
evaluation that leads to an…
A systematic
diagnostic evaluation
begins with a
thorough history!
Head and Neck Neoplasms:
Appropriate Assessment
A systematic
diagnostic evaluation
begins with a
thorough history!
Age
Young adult:
• Congenital
• Inflammatory
• Neoplastic
Head and Neck Neoplasms:
Appropriate Assessment
Pediatric :
• >90%
inflammatory
(infectious)
After age 40 :
• 80% of all non-
thyroid neck
masses are
neoplastic
• approximately 80%
of these are
malignant.
A systematic
diagnostic evaluation
begins with a
thorough history!
Age
Race
Head and Neck Neoplasms:
Appropriate Assessment
A systematic
diagnostic evaluation
begins with a
thorough history!
Age
Race
Duration
Clearly acute:
Inflammatory
Clearly chronic:
Congenital
Head and Neck Neoplasms:
Appropriate Assessment
A systematic
diagnostic evaluation
begins with a
thorough history!
Age
Race
Family History
Head and Neck Neoplasms:
Appropriate Assessment
A systematic
diagnostic evaluation
begins with a
thorough history!
Risk Factors
• Tobacco
• Alcohol Wynder et al JAMA,1956
Head and Neck Neoplasms:
Appropriate Assessment
A systematic
diagnostic evaluation
begins with a
thorough history!
Risk Factors
• Sexual
behavior
Head and Neck Neoplasms:
Appropriate Assessment
SCCA: UPPER AERODIGESTIVE TRACT
1975-2008
American Cancer Society
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Pharynx
Oral Cavity/Lip
Presence of HPV in Tonsil SCC
0
10
20
30
40
50
60
70
80
1970-1979 1980-1989 1990-1999 2000-2002
Hammarstedt L et al. Int J Cancer 119:2620, 2006
HPV Subtypes:
– Low Risk Types: 6, 11 Papillomas
– High Risk Types: 16, 31, 33 OrophayrngealCarcinoma
– HPV 16 >90% of HPV + H&N cancers
Head and Neck Neoplasms:
Appropriate Assessment
A systematic
diagnostic evaluation
begins with a
thorough history!
Risk Factors
• Sexual
behavior
HPV Related Tumors
● Male predominance
● Younger patients
● Fewer traditional risk factors
● Sexual behavior as risk factor
Multiple sexual partners (>6)
Higher rates of oro-genital contact
with multiple partners
Head and NecK Neoplasms
Other Risk Factors:
● Genetic predisposition (p53 mutation)
● Fanconi’s anemia
● Li Fraumeni Sdr
● HPV
● Immunosuppression
A systematic
diagnostic evaluation
begins with a
thorough history!
Risk Factors
• Sun exposure/
damage
Head and Neck Neoplasms:
Appropriate Assessment
UV Radiation: Type of Exposure
Young C. Occupational Medicine. 59:82, 2009
Cumulative recreational
and occupational
exposure: highest risk of
SCC
Sunburns highest risk for
BCC and melanoma
UV Radiation: Type of Exposure
Cumulative recreational
and occupational
exposure: highest risk of
SCC
Sunburns highest risk for
BCC and melanoma
Young C. Occupational Medicine. 59:82, 2009
Pooled Analysis of Sun-exposure Pattern5700 melanoma cases/ 7216 controls
Chang YM et al. Int J Epidemiol 38:814, 2009
Chronic/occupational
exposure
Intermittent intense
exposure especially
during childhood
Pooled Analysis of Sun-exposure Pattern5700 melanoma cases/ 7216 controls
Chang YM et al. Int J Epidemiol 38:814, 2009
Chronic/occupational
exposure
UV Radiation: Type of Exposure
Tanning Beds
Meta-analysis of Epidemiological Studies on Indoor Tanning (IT) and
Risk for Melanoma, Squamous Cell Carcinoma and Basal Cell
Carcinoma
UV Radiation: Type of Exposure
Tanning Beds
Meta-analysis of Epidemiological Studies on Indoor Tanning (IT) and
Risk for Melanoma, Squamous Cell Carcinoma and Basal Cell
Carcinoma
UV Radiation: Type of Exposure
Tanning Beds
The International Agency for Research on Cancer Working Group. Int J Cancer 120:1116, 2007
ExposureNumber of
studiesRelative Risk
Melanoma
Ever use of IT
Exposure in youth
19
7
1.15*
1.75*
Squamous Cell
Carcinoma
Ever use of IT
3 2.25*
Basal Cell Carcinoma
Ever use of IT 41.03
Thorough History: SYMPTOMS
● Sore Throat
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
● Nasal obstruction (snoring): Recent onset, unilateral
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
● Nasal obstruction (snoring)
● Unilateral hearing loss
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
● Nasal obstruction (snoring)
● Unilateral hearing loss
● Dysphagia
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
● Nasal obstruction (snoring)
● Unilateral hearing loss
● Dysphagia
● Epistaxis
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
● Nasal obstruction (snoring)
● Unilateral hearing loss
● Dysphagia
● Hoarseness, hemoptysis
Thorough History: SYMPTOMS
● Sore Throat
● Otalgia, unilateral
● Nasal obstruction (snoring)
● Unilateral hearing loss
● Dysphagia
● Epistaxis
● Malaise, Weight loss, Night sweats, Fever
Thorough History: SYMPTOMS
Head and Neck Neoplasms
Diagnostic Evaluation
Physical Exam:
● The upper aero-digestive tract.
Pre-Malignant ChangesLeukoplakia (White Patch)
Risk of Invasive
Cancer
0.13 – 17.5%
Pre-Malignant Changes
Erythroplakia (Red Patch)
Risk of Invasive
Cancer
30%
● Submucous Fibrosis
● Lichen Planus (?)
● Syphilis (?)
Oral Cancer: Pre-Malignant Lesions
Oral Cancer: Pre-Malignant Lesions
● Submucous Fibrosis
● Lichen Planus (?)
● Syphilis (?)
35 y.o. snuff user
for 15 years,
asymptomatic
64 y.o. snuf user
for >30 years, has
sore lesions in entire
left cheek mucosa
Head and Neck Neoplasms
Clinical Presentation
Ulcerative
Head and Neck Neoplasms
Clinical Presentation
Endophytic
Head and Neck Neoplasms
Clinical Presentation
Exophytic
Head and Neck Neoplasms
Clinical Presentation
Exophytic
Head and Neck Neoplasms
Clinical Exam
Palpation!!
Head and Neck Neoplasms
Clinical Exam
Palpation!!
Head and Neck Neoplasms
Clinical Exam
Oropharynx and
Larynx
Head and Neck Neoplasms
Clinical Exam
Oropharynx and
Larynx
Head and Neck Neoplasms
Diagnostic Evaluation
Physical Exam:
● Neck nodes at risk
EXAMINATION OF THE NECK
The location of the
mass may guide to the
location of the primary
tumor
EXAMINATION OF THE NECK
The location of the
mass may guide to the
location of the primary
tumor
Central
Congenital
EXAMINATION OF THE NECK
The location of the
mass may guide to the
location of the primary
tumor
Central
Congenital
Lateral:
Congenital
(BCCyst)
Inflammatory
Cat Scratch
Castleman’s
Traumatic
Neoplastic
Oral CavitySkin Face
Oral Cavity, Pharynx, Larynx
Larynx, Hypopharynx,
Thyroid
Nasopharynx,Tonsil
ThyroidBelow Clavicle
62 y.o. presents wit
an asymptomatic
mass he first noted
2 months ago.
Feels rubbery hard ,
somewhat mobile,
non-tender
H&N Exam:
Neck Mass in the Adult
Primary Tumor
Found
Appropriate:
Biopsy
Imaging
Treatment
Neck Mass in the Adult
Neck Mass in the Adult
Primary
Tumor “NOT
Found”
Ultrasound
CT Scan
MRI
PET
A systematic
diagnostic evaluation
:
Additional
Tools
FNA
Neck Mass: Appropriate Assessment
31 y. o. Healthy
Asymptomatic mass
present 2 years
Feels soft, fluctuant
Adequate Management of a Neck Mass
Clinical Situations
Surgery
19 y. o. Healthy
Felt a small lump in the
area for “a long time
URI 10 days prior
Rapid swelling and
tenderness
I & D
Adequate Management of a Neck Mass
Clinical Situations
41 y. o. Healthy
Asymptomatic mass
present 2 years, slowly
enlarging
Feels rubbery, barely
mobile
Complete Clinical Exam
US
Adequate Management of a Neck Mass
Clinical Situations
NECK MASS: FNA
Specificity 94-99%
Sensitivity 92-98%
Interobserver Variability +8%
NECK MASS: FNA
Easily performed in the outpatient setting
Will not interfere with subsequent surgical treatment.
May provide a specimen for culture.
May distinguish cystic from solid masses.
FNA: TECHNIQUE
Local Anesthesia (30 g. needle)
Needle size: 25 gauge
12-15 Passes
On-site slide preparation: Cytotechnologist
Immediate assessment of adequacy: Pathologist *
*Schmidt et al. The Influence of rapid Onsite Evalaution on the Adequacy
Rate of FNA Cytology. Asystematic review of the Literature and Meta-
Analysis. Amer J Clin Pathol 139:300, 2013
Head and Neck Neoplasms
Comprehensive treatment of the patient with HEAD
AND NECK cancer is a multidisciplinary effort.
Head & Neck Oncology Teams
Head & Neck Surgeon
Radiation Oncologist
Medical Oncologist
Head & Neck Radiologist
Oral & Maxillo-Facial Surgeon
Cytopathologist
Surgical Pathologist
Dentist
H&N Physician’s Associate
Prosthodontist
Nurse/ Navigator
Speech Pathologist
Nutritionist
Physical Therapist
Social Worker
Treatment of Head and Neck Cancer
Early Stage T1-T2
Surgery = Radiation
Primary Tumor: Advanced
Stage
(T3-T4)
Combined Surgery and
Radiation
(+ Chemotherapy)
Treatment of Head and Neck Cancer
Primary Tumor: Advanced
Stage
(T3-T4)
Combined Surgery and
Radiation
(+ Chemotherapy)
Treatment of Head and Neck Cancer
Primary Tumor: Advanced
Stage
(T3-T4)
Combined Surgery and
Radiation
(+ Chemotherapy)
Treatment of Head and Neck Cancer
Primary Tumor: Advanced
Stage
(T3-T4)
Combined Surgery and
Radiation
(+ Chemotherapy)
Treatment of Head and Neck Cancer
Primary Tumor: Advanced
Stage
(T3-T4)
Combined Surgery and
Radiation
(+ Chemotherapy)
Treatment of Head and Neck Cancer
Advanced
Larynx
Cancer
“T4”
Total
Laryngectomy
Total
Laryngectomy
Total
Laryngectomy
Total
Laryngectomy
Total
Laryngectomy
Total
Laryngectomy
Laryngectomy: Current Care
Primary TEP
Patient able to
speak in 10 -12 days
Early Oropharyngeal Carcinoma
Evolution of Treatment
Radiotherapy
Surgery: Open
Surgery:
Transoral
Transoral Robot Assisted Surgery