Head & Neck Cancer Diagnosis Surgeon Perspective

Sunarto Reksoprawiro
Department of Surgery Faculty of Medicine, Airlangga University/ Dr. Soetomo Hospital Surabaya

INTRODUCTION Head and neck cancer

oral cavity pharynx paranasal sinuses nasal cavity larynx salivary glands

EPIDEMIOLOGY US (1992) Worldwide : 42,800 cases of head and neck cancer with 11,600 deaths. : more than 500,000 new cases are projected annually

RISK FACTORS Tobacco Alcohol Occupational risk factors :

nickel refining woodworking exposure to textile fibers

Epstein-Barr virus Radiation

PATHOLOGY squamous cell carcinomas (95%) lymphoepithelioma spindle cell carcinoma verrucous cancer undifferentiated carcinoma lymphoma

BIOLOGY Squamous-cell carcinomas (95%) Field of cancerization (upper aerodigestive tract, lungs, and esophagus) Multistep process of carcinogenesis
Deletion of chromosom 3p, 18q Amplification of EGFR, int-2, bcl-1 p53 mutation Alterations in differentiation antigens (cytokeratins, envelope proteins, blood-group antigens and other glycoproteins) occur in later stages of carcinogenesis

ORAL CANCER
(50% OF HEAD AND NECK CANCER)

incidence : 3% (males) and 2% (females) of all malignant neoplasms 5 YSR : 50%

PREMALIGNANT LESIONS
Leucoplakia

Erythroplakia

SIGNS AND SYMPTOMS OF ORAL CANCER

Mouth sore that does not heal within 2-3 weeks Mouth sore that bleed spontaneously Velvety white, red, or speckled (red and white) patch on the mouth that is persistent Hard, raised lesion (lump, crust, eroded areas on the lips gums, or other area inside the mouth Unexplained bleeding in the mouth Persistent pain in the mouth Difficulty chewing, swallowing, speaking, or moving the tongue

PHYSICAL EXAMINATION
Adequate light source Mouth mirror is essential Forceful protraction of the tongue

Primary tumor Inspection Palpation

Sign of malignancy Site / location Infiltration/ invasion to the surrounding tissue T determination

The Growth Form

Exophytic/ Fungating Infiltrative Ulcerative

Cancer of the lip

(95% lower lip, slow growing)

 ORAL CANCER Cancer of the tongue

 Cancer of the gum

Cancer of the buccal mucous

 Cancer of the palate

Cancer of the mouth floor

Regional Lymph nodes

Inspection Palpation
Site/ location/ level Size, consistency, mobility N determination

Head and neck lymph drainage

 CLINICAL DIAGNOSIS

DIAGNOSTIC TESTS
BIOPSY
CYTOLOGY
Scraping / brushing ( for superficial ulcerative lesion ) FNAB ( for mass lesion)

TISSUE BIOPSY
Excisional biopsy ( for lesion < 1 cm ) Incisional biopsy ( for lesion > 1 cm )

IMAGING Extention of primary tumor (T)

Panoramic, Waters CT scan, MRI

 Cervical lymph nodes metastasis (N)

USG, CT scan, MRI

 Distant metastasis (M)

Chest X ray photo USG upper abdomen Tc scan, PET scan

STAGING ( TNM ) PREOPERATIVE

 INTRAOPERATIVE
Suprahyoidal dissection ( for lip cancer ) Supraomohyoidal dissection ( for oral cancer )

Sentinel node biopsy ( for lip and oral cancer ) Radioisotope Blue dye

T Staging for Tumors of the Lip and Oral Cavity

TX T0 Tis T1 T2 T3 T4a Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Tumor 2 cm or less in greatest dimension Tumor more than 2 cm but not more than 4 cm in greatest dimension Tumor more than 4 cm in greatest dimension

Lip Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (ie, chin or nose)* Oral Cavity Tumor invades through cortical bone, into deep [extrinsic] muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face

T4b Tumor involves masticator space, pterygoid plates, or skull base and/or encases internal carotid artery

N Staging for Tumors of the Lip and Oral Cavity

Nx N0 N1 Regional lymph nodes cannot be assessed No regional lymph node metastasis Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3 Metastasis in a lymph more than 6 cm in greatest dimension

Stage Grouping
I : T1 N0 M0 II : T2 N0 M0 III : T3 N0 M0/ T1 N1 M0/ T2 N1 M0/ T3 N1 M0 IVA : T4a N0 M0/ T4a N1 M0/ T1 N2 M0/ T2 N2 M0/ T3 N2 M0/ T4a N2 M0 IVB : T4b Any N M0/ Any T N3 M0 IVC : Any T Any N M1

SALIVARY GLAND CANCER

SALIVARY GLAND MAJOR
Parotid gland Submandibular gland Sublingual gland : malignancy 30% : malignancy 50% : malignancy 70%

MINOR
Submucosal upper aerodigestive tract
: malignancy - > 90%

PAROTID GLAND CANCER SYMPTOM

EARLY
Mass in the posterior cheek region

LATE
Pain ( local, auditory canal ) Asymmetry of the face Numbness of trigeminal nerve Trismus Dysphagia

 PHYSICAL EXAMINATION
Hard in consistency Infiltration ( skin, soft tissue) Facial nerve paresis Intra oral : deviation of soft palate Enlargement of cervical lymph node

 IMAGING
Signs of malignancy Cervical lymphnodes metastasis
USG CT scan

 TISSUE DIAGNOSIS
FNA FROZEN SECTION OPEN BIOPSY

STAGING (TNM)

T Staging for Parotid Tumors

Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Tumor 2 cm without extraparenchymal extension Tumor >2-4 cm without extraparenchymal extension Tumor having extraparenchymal extension without 7th nerve involvement and/or >4 cm T4a Tumor invades skin, mandible, ear canal, and/or facial nerve T4b Tumor invades skull base and/or pterygoid plates and/or carotid artery TX T0 Tis T1 T2 T3

N,M Staging for Parotid Tumors

N1 Metastasis in a single lymph node, 3 cm N2 Metastasis in a single lymph node, 3-6 cm; Multiple ipsilateral, bilateral or contralateral lymph nodes 6 cm N3 Metastasis in a lymph node >6 cm M1 Distant metastasis

Staging
I II III IVA T1N0M0 T2N0M0 T3N0M0/ T1N1M0/ T2N1M0/ T3N1M0 T4aN0M0/ T4aN1M0/ T1N2M0/ T2N2M0/ T3N2M0/ T4aN2M0 T4bNM0/ Any T N3M0 Any T any N M1

IVB IVC

 >70% patients will present in late stage (III, IV) OPERABILITY TREATMENT MODALITIES CHOICE OF TREATMENT FOLLOW-UP PROGNOSIS

MOST IMPORTANT
PREVENTION
Say No to Tobacco and Alcohol

EARLY DETECTION
Health education Physical diagnosis Toluidine blue

AVOID DOCTOR DELAY