head and neck neoplasms · 2019-09-13 · jesus e. medina, m.d. head and neck neoplasms jesus e....

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.


● 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


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”


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.


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


begins with a

thorough history!

Age

Young adult:

• Congenital

• Inflammatory

• Neoplastic



Pediatric :

• >90%

inflammatory

(infectious)

After age 40 :

• 80% of all non-

thyroid neck

masses are

neoplastic

• approximately 80%

of these are

malignant.

A systematic


begins with a

thorough history!

Age

Race



A systematic


begins with a

thorough history!

Age

Race

Duration

Clearly acute:

Inflammatory

Clearly chronic:

Congenital



A systematic


begins with a

thorough history!

Age

Race

Family History



A systematic


begins with a

thorough history!

Risk Factors

• Tobacco

• Alcohol Wynder et al JAMA,1956



A systematic


begins with a

thorough history!

Risk Factors

• Sexual

behavior



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



A systematic


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


begins with a

thorough history!

Risk Factors

• Sun exposure/

damage



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


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

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fwww.theguardian.com%2Fbusiness%2F2010%2Fnov%2F16%2Frok-collapse-job-losses&ei=DIwIVe6ZFMaeNpDGgYgB&psig=AFQjCNHXBf9HSQZJvmlaM0iU20-nX2yhIg&ust=1426709784483794

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fpl.123rf.com%2Fphoto_18071538_3d-%25C3%2585%25E2%2580%25BAwiadczonych-ilustracji---m%25C3%2584%25E2%2584%25A2%25C3%2585%25C2%25BCczy%25C3%2585%25C2%25BAni-mi%25C3%2584%25E2%2584%25A2%25C3%2585%25E2%2580%25BAnie.html&ei=9ZUIVdmJLtOTNrbZgaAN&bvm=bv.88198703,d.eXY&psig=AFQjCNH5ebT0tCiqHNCl5BKT3PLPioHYtg&ust=1426712262403728

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fdoctorv.ca%2Fmedical-conditions%2Fskin-cancer%2Factinic-keratoses%2F&ei=C5gIVanHHYKINpj3gPgH&bvm=bv.88198703,d.eXY&psig=AFQjCNHUIFGj5UtxRLWRmrP8liopXJQz6Q&ust=1426712959846526

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

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fwww.theguardian.com%2Fbusiness%2F2010%2Fnov%2F16%2Frok-collapse-job-losses&ei=DIwIVe6ZFMaeNpDGgYgB&psig=AFQjCNHXBf9HSQZJvmlaM0iU20-nX2yhIg&ust=1426709784483794

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fpl.123rf.com%2Fphoto_18071538_3d-%25C3%2585%25E2%2580%25BAwiadczonych-ilustracji---m%25C3%2584%25E2%2584%25A2%25C3%2585%25C2%25BCczy%25C3%2585%25C2%25BAni-mi%25C3%2584%25E2%2584%25A2%25C3%2585%25E2%2580%25BAnie.html&ei=9ZUIVdmJLtOTNrbZgaAN&bvm=bv.88198703,d.eXY&psig=AFQjCNH5ebT0tCiqHNCl5BKT3PLPioHYtg&ust=1426712262403728

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fwww.webmd.com%2Fskin-problems-and-treatments%2Fpicture-of-dysplastic-nevi-atypical-moles&ei=rpcIVeyPK8fUggTewoIg&bvm=bv.88198703,d.eXY&psig=AFQjCNH4finyAM0IhIeVXIHdda8a15mLAw&ust=1426712871900456

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http%3A%2F%2Fdoctorv.ca%2Fmedical-conditions%2Fskin-cancer%2Factinic-keratoses%2F&ei=C5gIVanHHYKINpj3gPgH&bvm=bv.88198703,d.eXY&psig=AFQjCNHUIFGj5UtxRLWRmrP8liopXJQz6Q&ust=1426712959846526


Tanning Beds

Meta-analysis of Epidemiological Studies on Indoor Tanning (IT) and

Risk for Melanoma, Squamous Cell Carcinoma and Basal Cell

Carcinoma


Tanning Beds

Meta-analysis of Epidemiological Studies on Indoor Tanning (IT) and

Risk for Melanoma, Squamous Cell Carcinoma and Basal Cell

Carcinoma


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


● Sore Throat

● Otalgia, unilateral


● Sore Throat


● Nasal obstruction (snoring): Recent onset, unilateral


● Sore Throat


● Nasal obstruction (snoring)

● Unilateral hearing loss


● Sore Throat




● Dysphagia


● Sore Throat




● Dysphagia

● Epistaxis


● Sore Throat




● Dysphagia

● Hoarseness, hemoptysis


● Sore Throat




● Dysphagia

● Epistaxis

● Malaise, Weight loss, Night sweats, Fever



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


Clinical Presentation

Ulcerative



Endophytic



Exophytic


Clinical Exam

Palpation!!


Clinical Exam

Oropharynx and

Larynx

http://www.docvadis.it/fabiocolaboni/content/docvadisRoot/sites/fabiocolaboni/documents/fibrolaringoscopia/data/1290685320844Original.jpg


Clinical Exam

Oropharynx and

Larynx

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCOrU7uOQjMgCFQOcgAodjQcPcA&url=http%3A%2F%2Fwww.ohniww.org%2Fthe-misdiagnosis-of-vocal-nodules%2F&bvm=bv.103388427,d.eXY&psig=AFQjCNFCHvHUCovyM750XJrd2Wmokuz30Q&ust=1443062423084713


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


The location of the



tumor

Central

Congenital


The location of the



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


Primary

Tumor “NOT

Found”

Ultrasound

CT Scan

MRI

PET

A systematic


:

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


Clinical Situations

41 y. o. Healthy

Asymptomatic mass

present 2 years, slowly

enlarging

Feels rubbery, barely

mobile

Complete Clinical Exam

US


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


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

Advanced

Larynx

Cancer

“T4”

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

head and neck neoplasms · 2019-09-13 · jesus e. medina, m.d. head and neck neoplasms jesus e....

Documents