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. Hodgkins & non-Hodgkins 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. 2. 3. 4. Grade 0 Grade 1 Grade 2 Grade 3 Fully active without restriction Ambulatory but restricted in physically strenuous activity Ambulatory but unable to carry out any work activity Confined to bed but capable of limited self care Confined to bed and unable to carry out any self care
Karnofsky Status

5.

Grade 4

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 T1 4, N1 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 nonkeratinizing 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 anterolateral 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 parapharyngyeal 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