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HEAD and NECK Case1

Monica Kristine D. Reyes

Given
1. 45 year old man 2. 1x2cm firm, movable, non-tender mass: right side of neck at level II. 3. Patient took no notice: thought it was reactive lymphadenopathy (had cold). 4. 4 weeks later: enlarged- 3x2cm 5. No other pertinent neck findings. 6. Posterior Rhinoscopy: reddish mass at the fossa of Rosenmuller on the right (confirmed on nasal endoscopy) 7. Punch biopsy; undifferentiated CA

Recall
Level II: Skull base, Hyoid Bone, Submandibular Gland, Sternocleidomastoid Muscle The Level II lymph nodes extend from the skull base, at the lower level of the bony margin of the jugular fossa, to the lower margin of the body of the hyoid bone. Level II nodes are located anterior to a transverse line connecting the posterior edge of the sternocleidomastoid muscles and posterior to a transverse line connecting the posterior edge of the submandibular glands. Level IIA: These are Level II lymph nodes that are located anterior, medial or lateral to the internal jugular vein. These also define Level II lymph nodes that are posterior to the internal jugular vein but directly abut the vein(22, 23). Level IIB: These nodes are posterior to the internal jugular vein and have an identifiable fat plane between the lymph node and the vein(22, 23).

Recall
Rosenmuller fossa boundaries: 1. Anterior: Eustachean tube and levator veli palati muscle. 2. Posterior: Pharyngeal wall mucosa overlying the pharyngobasilar fascia and retro pharyngeal space, containing the retropharyngeal lymph nodes of Rouviere. 3. Medial: Nasopharyngeal cavity. 4. Superior: Foramen lacerum and floor of the carotid canal. 5. Postero lateral (apex): Carotid canal opening and petrous apex posteriorly, foramen ovale and spinosum laterally. 6. Lateral: Tensor palati muscle, mandibular nerve and the prestyloid compartment of the para pharyngeal space.

Recall
Punch biopsy:

The use of a biopsy punch in oral mucosal lesions is described and may be of some value. Punch biopsy may be difficult on freely movable oral tissues and probably offers no advantage compared with scalpel biopsy. The technique may be appropriate in the hard palate and other sites with better support and tissue that is bound down, and it is likely to produce a satisfactory specimen. The wound heals by secondary intention, and discomfort may persist longer than anticipated by the clinician and the patient.

Diagnosis
Nasopharyngeal Carcinoma metastasizing to the right cervical lymph nodes, level II WHO-3 category

Differentials
I knowhindi tinatanongpero isama ko na rin Look up spondylosis, benign mixed tumor of the salivary glands, mucoepidermoid carcinoma and cervical disc herniation

But since, nagbiopsy na ngaduh? =)

What personal and social history information would contribute to the diagnosis?
Sex. Men have about double the risk of developing cancer of the nasopharnyx as women do. Race. This type of cancer more commonly affects people in Asia and northern Africa. In the United States, Asian immigrants have a higher risk of this type of cancer than do Americanborn Asians, which may be related to differences in diet. The Inuits of Alaska also have an increased risk of nasopharyngeal cancer. Additionally, blacks are significantly more likely to develop nasopharyngeal cancer than are whites. Age. Most cases of nasopharyngeal cancer occur in people between the ages of 30 and 55. Salt-cured foods. Chemicals released in steam when cooking salt-cured foods, such as fish, preserved vegetables and Chinese herbs, may enter the nasal cavity, increasing the risk of nasopharyngeal carcinoma. In China, nasopharyngeal carcinoma has been linked to high consumption of salted fish, and as people in Southeast China are adopting a more Western diet, their rates of nasopharyngeal cancer have been declining. Preserved meats. Preserved meats contain high levels of nitrates, which may increase the risk of nasopharyngeal carcinoma. ; high incidence in those with low vegetable consumption (carotenoids are protective) Epstein-Barr virus. This common virus usually produces mild signs and symptoms, such as those of a cold. Sometimes it can cause infectious mononucleosis. Epstein-Barr virus is also linked to several rare cancers, including nasopharyngeal carcinoma. In fact, the Epstein-Barr virus can be found in almost all nasopharyngeal cancer cells. Family history. Having a family member with nasopharyngeal carcinoma increases your risk of the disease, though researchers aren't sure if this association is due to genetic or environmental factors. Smoking and alcohol use (including smokeless tobacco)

Is a Neck mass common for this diagnosis?


The most common physical finding is a neck mass, which is observed in 80% of patients. Painless firm lymph node enlargement is present. http://emedicine.medscape.com/article/988165 -overview

Diagnostic Procedures
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Laboratories: Routine blood work, chemistry profile, CBC, liver function tests (rare cases of hepatic metastasis) EBV titers, IgA, IgG antibodies to viral capsid antigen (titers correlate with tumor burden) CSF exam: seeding of the tumor (if invasion to skull base is observed)

2. Imaging: a. CT: tumor extension, erosion of skull base, cervical lymphadenopathy, bone imaging (distant metastases) b. MRI: extent of tumor (intracranial extension) c. PET: questionnable neck nodes
3. Biopsy (WHO-3 is undifferentiated carcinoma, including lymphoepithelioma. This entity consists of malignant epithelial cells with lymphocytic infiltration)

Other Histopathology
Three subtypes of NPC are recognized in the World Health Organisation (WHO) classification [20]: type 1: squamous cell carcinoma, typically found in the older adult population type 2: non-keratinizing carcinoma type 3: undifferentiated carcinoma Most cases in childhood and adolescence are type 3, with a few type 2 cases [21]. Type 2 and 3 are associated with elevated Epstein-Barr virus titers, but type 1 is not [22]. The Cologne modification of the WHO scheme by Krueger and Wustrow [23] includes the degree of lymphoid infiltration. Types 2 and 3 may be accompanied by an inflammatory infiltrate of lymphocytes, plasma cells, and eosinophils, which are abundant, giving rise to the term lymphoepithelioma. Two histological patterns may occur: Regaud type, with a well-defined collection of epithelial cells surrounded by lymphocytes and connective tissue, and Schmincke type, in which the tumor cells are distributed diffusely and intermingle with the inflammatory cells. Both patterns may be present in the same tumor. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1559589

Treatment Options
1. Surgery: Due to the anatomical position of NPC and its tendency to present with cervical lymph node metastases, it is not amenable to surgery for local control. Biopsy of the involved lymph node is the usual surgical procedure. The nasopharyngeal primary tumor is rarely biopsied. Chemotheraphy: NOTE- doxorubicin, methotrexate and cyclophosphamide would produce infertility in boys (total dose of cyclophosphamide 12 gm/m2) and possible anthracycline toxicity (total dose of doxorubicin 360 mg/m2) (ok langmatanda nanaman siya e.); assess renal toxicitythis is usually for palliative care. Radiotherapy:The degree of pituitary dysfunction obviously depends on the radiotherapy field and, potentially, on the dose of radiotherapy but some degree of hypopituitarism is expected. Furthermore, irradiation to the neck would result in hypothyroidism for the majority of patients and irradiation to the oropharynx would result in xerostomia and resultant poor dentition. The later may be relieved by amifostine, as demonstrated in adult studies. (does not prevent distant metastases)

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More info on Radiotherapy


Radiotherapy is given with megavoltage equipment after initial chemotherapy. A maximum dose of 45 Gy is given to the clinical target volume, which is a 1 cm margin around the MRI-detected primary site, and inferiorly down to the clavicles to include the lymph nodes. Treatment is given in two phases: Phase I parallel pair (mostly lateral unless the tumor extends anteriorly between the eyes). Eyes, brain and brain stem are shielded as much as possible. A midplane dose of 30 Gy in 15 fractions is given. Phase II a lateral parallel pair or three-fields technique is used for the primary site, delivering 15 Gy in seven fractions to the clinical target volume of the tumor with a 1 cm margin. Brain stem and eyes should be shielded. Any overlap with the neck field should be shielded. A matching anterior neck node field is used to deliver a prescribed maximum subcutaneous dose of 15 Gy in seven fractions. The spinal cord should be shielded in this field. This prescription for radiotherapy is used in Manchester, but it is recognized that higher doses may be used in some centers, possibly to a total of 60 Gy to the tumor volume. In an current GPOH study, patients in complete remission (CR) after three courses of chemotherapy, will have their radiotherapy dosage reduced to 54 Gy instead of 59 Gy.

Management after Biopsy and Rationale behind Tx option


1. 2. Physical exam of the throat: An exam in which the doctor feels for swollen lymph nodes in the neck and looks down the throat with a small, long-handled mirror to check for abnormal areas. Nasoscopy: A procedure to look inside the nose for abnormal areas. A nasoscope is inserted through the nose. A nasoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer. Neurological exam: A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks a persons mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam. Head and chest x-rays: An x-ray of the skull and organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

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Management after Biopsy and Rationale behind Tx option


6. CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. 7. PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. PET scans may be used to find nasopharyngeal cancers that have spread to the bone. 8. Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or other substances in the body. These tests help to diagnose disease, plan and check treatment, or monitor the disease over time. 9. Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer.

Radio vs. Chemorad vs. Chemotherapy


Chemotherapy: for unresected tumors; improves likelihood of disease compared to irradiation alone. Even in the absence of survival improvement, there seemed to be a correlation between response to the chemotherapy and subsequent response to radiation (less distant metastases)- 3-fold decrease in mortality Radiotherapy: 1.fixed neck nodes, 2. delayed more than 8 weeks post-op for reconstruction, 3. open biopsy for a positive neck node, 4. risk of recurrence above clavicles exceeds 20% (should be no later than 6 to 8 weeks) -delikado

END
Nica =)