SURG Prelim LEC 3 - TUMORS OF HEAD AND NECK Areas of Concern Hemangiomas and vascular malformations

Dr. Bartolome May , 2011 Nasal cavity

Pharynx Hemangiomas
CASE o Nasopharynx True neoplasm; may be absent at birth
27 years old male presented with a mass over the o Oropharynx Mostly resolves spontaneously
left submandibular area accompanied by pain o Hypopharynx Treatment only if with complications
and tenderness Larynx o Steroids systemic / intralesional
(+) redness and flactuant to tounch Oral cavity o Sclerosis
Diagnosis? Neck o Photodynamic laser treatment
o SKIN ABSCESS o surgery
Anomaly in thyroid gland development
o SUBMANDIBULARBULAR GLAND TUMOR Diagnosis
Midline neck mass in children
o CERVICAL LYMPHADENITIS Clinical History and Physical Examination Vascular malformations
Elevates on tongue protrusion
o METASTATIC CERVICAL LYMPH NODES Symptoms
ptoms referrable to upper aerodigestive tract Not a true neoplasm
Tx: Complete excision / SISTRUNK
WITH SECONDARY INFECTION Palpable and visible mass; cervical Error in vascular morphogenesis
Treatment ? lymphadenopathy Capillary, venous, arterial or lymphatics in
Branchial cleft cysts and sinuses
o Antibiotics and warm compress Bimanual examination if needed classification
o Antibiotics alone Ancillary procedures Present at birth; will not regress
o Excision of the mass o Endoscopy CT and MRI is usually helpful
o Incision, drainage and anibiotics
Nasopahryngolaryngoscopy Surgery often needed

Upper GI endoscopy o Indications: recurrent infection,
Case 2
bronchoscopy obstruction, hemorrhage, signi
ignificant
59 years old male presenting with a progressively o Biopsy aesthetic deformity
enlarging mass in the oral cavity
Fine needle aspiration
PE: 6 X 8 cm, mass originating from the hard
Incision/punch
Incision biopsy Spectrum of lesions in the head and neck area
palate mucosa with sign of bleeding and necrosis o Imaging
Diagnosis ?
Simple x-rays
x
o Squamous cell carcinoma of the oral
Ct-scan
scan
Second branchial cleft anomaly
cavity
MRI
o Most common
o Squamous papilloma, oral cavity
First branchial cleft anomaly
o Hemangioma CONGENITAL LESIONS OF THE HEAD AND NECK AREA
o Mass medial to tragus
o Lymphangioma Congenital lesions
Third branchial cleft anomaly
Treatment ? Thyroglossal duct cyst
o rare
o Excision Branchial cleft cysts and sinuses
o Wide Radical Excision with neck Hemangiomas
dissection Vascular malformations
o External Beam Radiation o Lymphangiomas
o Sclerotherapy o Cystic hygromas

Thyroglossal duct cyst

 Ulcerative lesions of the oral cavity PARANASAL SINUSES Odontogenic and Bone Tumors
BENIGN LESIONS / TUMORS OF THE Odontogenic tumors
HEAD AND NECK AREA Idiopathic aphthous ulcer Mucus retention cyst Tumors arising from progenitors of tooth
Most common; cycle of painful ulcer and healing Blockage of secretions of mucous glands within the development
Viral infection (herpes simplex) lining of the paranasal sinus cavity; usually a sequelae Usually involving the mandible and the maxilla
LIP
Nutritional deficiency B-complex vitamins of sinusitis Most are benign and treated conservatively
Chronic irritation; UV light exposure Ameloblastoma (adamantinomas)
Topical steroids or no treatment Fluid containing mass that results remains separate
Clinically as visible or palpable thickening From dental lamina often associated with
Pemphigus vulgaris from the bony wall of the sinus and so continues to be
Lip scaling dyskeratosis or ca-in-situ impacted tooth in a young patient;
Multiple painful ulcers surrounded by air within the sinus, except at its base.
Treatment: Painless jaw mass
In critically ill or severely toxic patients Most common in the maxillary sinus (considered the
o Lip-shaving Multilocular radiolucent appearance on x-ray
5th 6th decade of Mediterranean descent most common benign condition of the maxilla)
o Wide-excision Slow growing yet may erode to adjacent bone
Nikolskys sign intraepithelial bullae that ruptures Treatment rarely necessary
o Reconstruction Treatment: resection with adequate margin to
and ulcerate Mucocoeles
prevent local recurrence
TX: systemic steroids and antimetabolites Benign and expansile, highly destructive lesion
ORAL CAVITY Others:
Necrotizing Sialometaplasia Microscopic blockage of a sinus ostium by epithelial
Myxomas and Pindborg tumors (calcifying epithelial
Inflammatory ; Minor salivary glands in hard palate or osseous neoplasms, inflammatory process or as a
Mucus retention cyst or mucocoele odontogenic tumors) : behave similarly as
Discrete painful ulcers result of trauma
Submucosal accumulation of mucus ameloblastomas and treated the same way
Local trauma and progressive local ischemia Thinning and destruction of the sinus wall; mucocele
Common in the labial mucosa of lower lip Calcifying odontogneic cysts (Gorlins cysts),
Spontaneous healing in 6 10 weeks can invade adjacent vital structures ameloblastic fibromas, cementomas and keratocysts:
Small, smooth, rounded and bluish
Biopsy to differentiate malignancy CT or MRI may be needed gnerallay less aggressive and treated effectively with
Treatment: excision or marsupialization
White sponge nevus, Lichen planus, Oral hairy leukoplakia Treatment: evacuation and removal of entire mucosal enucleation and excision of the entire lining of lesion
Peripheral Giant Cell granuloma
White plaque lesions; Parakeratosis histologically lining of the sinus
Common in gingiva; giant cell of origin resembling
Immune related and self-limiting Non-odontogenic tumors
an osteoclast
In HIV or AIDS patients Torus
Polypoid, submucosal and fibrous
May be associated with SCCA especially lichen planus Benign, slow-growing projection from surface of bone
May ulcerate and bleed
Torus-palatinus (midline of the hard palate)
X-ray: bone erosion
Torus-mandibularis (develops in the lingual surface of
Complete excision NOSE
LARYNX the mandible opposite the premolars, often
Central Giant cell granulomas bilaterally)
Bony in origin; expansile endosteal lesion in the Juvenile nasopharyngeal angiofibromas
Papilloma (laryngeal) At puberty and slow-growing
mandible; also in paranasal sinuses, orbit, cranial Highly expansible and destructive fibrovascular
Most common benign neoplasm; True vocal cords Ulceration mimicking mucosal neoplasm
vault and temporal bone neoplasms
Human papillomavirus; exophytic pedunculated Treatment by excision only if symptomatic
DDX: Typical in adolescent males (10-20 years of age)
masses Exostoses
o True giant cell tumor (malignant potential) Starts at superior nasal cavity; erode widely into the
Hoarseness Localized bone overgrowths
o Brown tumors of hyperprathyroidism paranasal sinuses, orbit, pterygomaxillary fossa and
Juvenile or adult type depending on the age of onset Common in the jaws
o Traumatic bone cyst middle cranial fossa
Adult type: solitary and rarely recur after excision Excision if symptomatic
o Fibrous dysplasia Early nasal obstruction and epistaxis; Late - Osteomas
anosmia, proptosis or cranial nerve dysfunction Juvenile: multiple and usually recur after treatment
TX: curettage is curative Slow-growing tumors of mature bone that arise
Tx: angiographic embolization followed by surgical Treatment: excision / laser obliteration
Papillomas within (intraosseous) or at the periphery of he
extirpation; radiation for residual disease Laryngocoele
Tongue and larynx involved bone
Herniation of the laryngeal ventricles
Human papillomavirus Peripheral lesions often attached to the cortical bone
Internal laryngocoele: confined to the larynx; presents
Soft, irregular, pedunculated by a dense pedicle; most commonly in the mandible
as enlargement of the false vocal cord at the lingual surface; may also involve the paranasal
Excision or cauterization
External laryngocoele: protrudes through the sinuses
Granular cell myoblastoma (Abrikossof 1926)
thyrohyoid membrane causing swelling in the anterior Excision advised when continued growth encroaches
Rare tumor of the tongue neck upon vital structures
Firm submucosal swelling in the tongue; may be Mixed laryngocele: combination of the above types
Fibrous dysplasia
mistaken with SCCA Chronic increases in intra-laryngeal pressure; singers
Benign bone disorder of unknown cause
Wide excision generally curative and musicians Cortical bone replaced by immature fibrous tissue
Management depends on aggressiveness of the lesion
Treatment: ligation of stalk or the laryngocele and : observation to extensive local resection and
repair of ventricular weakness reconstruction
Mandible and maxilla commonly involved
 LYMPHATIC ANATOMY OF THE HEAD AND NECK For rational treatment plan and prognostication Cancer of the oropharynx
Malignant head & neck tumors Three main groups of lymphatics in the head and neck

Anatomy:
Primarily of tumor size in the oral cavity,
area: oropharynx and major salivary glands; Oropharynx extends from the hard palate
Squamous Cell Carcinoma = 90% STRUCTURES OF TRANSITIONAL CERVICAL LYMPH superiorly to the hyoid bone inferiorly
Depends on extent of local involvement in the
Differences in natural history depends largely on THE WALDEYERS LYMPHATICS NODES Pathology
larynx, hypopharynx , and nasopharynx
the location of the tumor, the blood supply and RING SCCA; Less well-differentiated; deep infiltration is
Different staging for thyroid cancer, lymphoma
the lymphatic (palatine tonsils, (submental, (internal jugular
and melanoma common
Clinical Manifestations = Nonspecific lingual tonsils, submandibular, chain of nodes,
adenoids, and parotid, spinal accessory Minor salivary gland neoplasms and lymphomas-
adjacent retroauricular chain of nodes, Cancer of the oral cavity particularly Non-Hodgkins lymphoma involving
Treatment approach: MULTIDISCIPLINARY submucosal and occipital supraclavicular Boundaries of the oral cavity: the tonsil and other parts of the Waldeyers ring-
o Considerations: lymphatics) nodes) area) arise in this area
Anterior: border of the lips

EXTIRPATION of the tumor with Over all incidence of nodal involvement is 70%
Posterior: anterior tonsillar pillars, the posterior
adequate margins ROUTES OF LYMPHATIC SPREAD FROM COMMON HEAD aspect of the hard palate and the circumvallate

FUNCTIONAL end-result AND NECK SITES T stageoropharyngeal cancer
papillae of the tongue
ETIOLOGY of Head and Neck Cancer Lymph node group Primary Site Oropharynx
Pathology
1. ULTRAVIOLET RAYS (sunlight) SUBMENTAL Lower lip, anterior oral cavity, skin
95% SCCA T1 Tumor 2 cm or less in greatest dimension
2. TOBACCO SUBMANDIBULAR Lower lip, oral cavity, facial skin
preceeded by leukoplakia or erythroplakia T2 Tumor > 2 cm but 4 cm in greatest dim.
3. ALCOHOL SUBDIGASTRIC Oral cavity, oropharynx,
hypopharynx moderately or well-differentiated T3 Tumor > 4 cm in greatest dimension
4. OCCUPATIONAL RELATED
MIDCERVICAL Hypopharynx, base of tongue, 30% with clinical or subclinical LN involvement T4 Tumor invades adjacent structures (eg,
5. RACE
larynx, thyroid T stage oral cavity cancer cortical bone, soft tissues of neck, deep
6. RADIATION EXPOSURE LOWER CERVICAL Hypopharynx, thyroid, lung, TX Primary tumor cannot be assessed [extrinsic] muscle of tongue)
HISTORY gastrointestinal
T0 No evidence of primary tumor
Four (4) most common presenting symptoms: OCCIPITAL Scalp
Tis Carcinoma in situ Clinical Features
o PAIN POSTERIOR Nasopharynx, hypopharynx, thyroid
TRIANGLE T1 Tumor 2 cm or less in greatest dimension Ulcerating lesions; nodal involvement in 60%
o BLEEDING
T2 Tumor > 2 cm but 4 cm in greatest dim. Base of tongue lesions diagnosed late
o OBSTRUCTION
MOST COMMON PRIMARY SITES IN PATIENTS T3 Tumor > 4 cm in greatest dimension Odynophagia or dysphagia;referred otalgia
o MASS
PRESENTING WITH NECK MASSES T4 Tumor invades adjacent structures Trismus indicates medial pterygoid muscle
PHYSICAL EXAMINATION
Nodal Level Primary Site involvement
o INSPECTION/PALPATE (Bimanual Exami)
I Anterior tongue Clinical Features
o Detailed NEUROLOGIC EXAMINATION
Floor of mouth Ulcerated tumors;50 70 years of age, males Treatment: CONTROVERSIAL
Diagnosis of head and neck cancer Anterior alveolar ridge
heavy smoking and alcohol use; poor dental Small tumors (T1 and T2)
BIOPSY II Oropharynx
hygiene o Surgery or Radiotherapy same results
o PUNCH BIOPSY Nasopharynx
Not painful unless deeply invasive o Small tonsillar cancer respond well to
o INCISIONAL BIOPSY III Hypopharynx
Larynx Clinically palpable nodes in 30% radiotherapy
o FINE NEEDLE ASPIRATION BIOPSY (on
Lateral tongue Treatment: Large tumors
neck nodes)
IV Usually subclavicular SURGERY wide resection with indicated neck o Surgery + postop RT
o Exception
V Scalp dissection; COMANDO surgery o Preop RT then surgery

Very small lesions that can be
Nasopharynx
completely removed by same Staged bilateral neck dissection if lesion crosses
Parotid gland
biopsy procedure the midline

Salivary gland/Parotid gland tumor STAGING OF HEAD AND NECK CANCER Radiation may be used for smaller lesions away
ADDITIONAL STUDIES TNM CLASSIFICATION from the mandible or for recurrence of disease
o RADIOLOGIC STUDIES Accurate physical assessment must be done to
o CT SCAN accurately stage head and neck cancer
o MRI preopretaively. A chart must be utilized to draw
o CONTRAST STUDIES / BARIUM SWALLOW the lesions
Cancer of the hypopharynx
From the hyoid bone superiorly to the lower
border of the cricoid cartillage inferiorly
Four subsites
o The piriform sinuses (one on each side of
the larynx)
o The postcricoid area (immediately behind
the larynx)
o The posterior pharyngeal wall
o The marginal area where the medial
wall of the piriform sinus and the false
vocal cord meet superiorly at the
aryepiglottic fold
Three times more common than laryngeal
carcinoma
Related to tobacco use, alcohol use and
Plummer-Vinson syndrome
Usually well-differentiated
T stagecancer of the hypopharynx
T1 Tumor limited to one subsite of hypopharynx
T2 Tumor invades more than one subsite of
hypopharynx or adjacent site, without fixation of
hemilarynx
T3 Tumor invades more than one subsite of
hypopharynx or adjacent site, with fixation of
hemilarynx
T4 Tumor invades adjacent structures (eg, cartilage,
soft tissues of neck)
Symptoms
Dysphagia aspiration pneumonia
Palpable cervical lymph node
Treatment
Wide resection of larynx and hypopharynx with
en bloc radical neck dissection standard
treatment
Reconstruction
o PLO (pharyngolaryngo-oesophagectomy)
and gastric pull-up or colonic
interposition for reconstruction
CARCINOMA OF THE NASOPHARYNX
UNCOMMON; Increased incidence among
Chinese
Lymphoid and epidermoid element
Symptoms
o Respiratory obstruction nasal stuffiness
o Palsies of CN III, IV, V, VI - cavernous
sinus invasion
o Horners syndrome cervical
sympathetic chain
Treatment
o Radiation for primary and metastatic
disease
o Neck dissection for residual neck nodes
after RT-control of the primary tumor
o 5-year survival 25 30%
T stagenasopharyngeal cancer
T1 Tumor limited to one subsite of nasopharynx
T2 Tumor invades more than 1 subsite of nasopharynx
T3 Tumor invades nasal cavity or oropharynx
T4 Tumor invades skull or cranial nerve
Carcinoma of the nasal cavity and paranasal sinuses
SCCA; advanced at presentation
Maxillary Antrum most common site
Other types: Adenocarcinoma, sarcoma,
melanoma, lymphoma and minor salivary gland
tumors
Diagnosis:
o Physical examination alone is often
difficult to accurately stage and delineate
the tumor
o CT scan and / or MRI
Treatment
o RADIOTHERAPY (primary treatment)
o Surgery for early staged disease
T stagemaxillary sinus cancer
T1 Tumor limited to antral mucosa, with no erosion
or destruction of bone
T2 Tumor with erosion or destruction of
infrastructure, including hard palate or middle
nasal meatus
T3 Tumor invades any of following: skin of cheek,
posterior wall of maxillary sinus, floor or medial
wall of orbit, anterior ethmoid sinus
T4 Tumor invades orbital contents or any of the
following: cribriform plate, posterior ethmoid or
sphenoid sinuses, nasopharynx, soft
palate, pterygomaxillary or temporal fossae, base
of skull
Cancer of the Larynx
Tobacco (especially when combined with alcohol)
is a recognized etiologic agent
o Men:women 10:1
o Supraglottic (above true vocal cords)
45%
o Glottic (involving vocal cord) 50%
o Subglottic (below vocal cord) less than
5%
Symptoms
o Hoarseness
o Respiratory distress
o Dysphagia (late manifestations)
T stageLaryngeal cancer: Supraglottis
T1 Tumor limited to one subsite of supraglottis, with
normal vocal cord mobility
T2 Tumor invades more than one subsite or
supraglottis or glottis, with normal vocal cord
mobility
T3 Tumor limited to larynx, with vocal cord fixation,
or invades postcricoid area, medial wall of
piriform sinus, or preepiglottic tissues
T4 Tumor invades thyroid cartilage or extends to
other tissues beyond larynx (eg, oropharynx, soft
tissue of neck)
Glottis
T1 Tumor limited to vocal cord (may involve anterior
or posterior commissures), with normal mobility
T1a Tumor limited to one vocal cord
T1b Tumor involves both vocal cords
T2 Tumor extends to supraglottis or subglottis or
with impaired vocal cord mobility
T3 Tumor limited to larynx with vocal cord fixation
T4 Tumor invades thyroid cartilage or extends to
other tissues beyond larynx (eg, oropharynx, soft
tissues of neck)
Subglottis
T1 Tumor limited to subglottis
T2 Tumor extends to vocal cord, with normal
or impaired mobility
T3 Tumor limited to larynx, with vocal cord
fixation
T4 Tumor invades through cricoid or thyroid
cartilage, or extends to other tissues beyond
larynx (eg, oropharynx, soft tissues of neck)
Treatment
SUPRAGLOTTIC
o Primarily radiation for small lesion
o More advanced tumor combined
radiation and surgery; either total or
partial laryngiectomy
GLOTTIC
o Radiation for early lesion
o Partial vs Total laryngiectomy
SUBGLOTTIC
o Usually present in more advanced stage
o Total laryngiectomy with neck dissection
Over-all 5 year survival of patients with
treatment by surgery is 50-65%
REGIONAL LYMPH NODE INVOLVEMENT
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in single ipsilateral lymph node, 3 cm
or less in greatest dimension
N2 Metastasis in 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 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 lymph node, more than 6 cm in
greatest dimension

Unknown primary cancers of the
head and neck
In about 5 10% of metastatic tumor in the neck,
the primary tumor is clinically occult
RULE of 80s
o 80% of non-thyroid masses are
neoplastic
o 80% of neoplastic lesions are malignant
o 80% of malignant masses are metastatic
o 80% of primary tumors are located above
the clavicle
History and Physical examination
Panendoscopy - QUAD SCOPES:
o Nasopharyngoscopy, Laryngoscopy,
Bronchoscopy, Esophagosopcy
Suspicious lesions are biopsied
o Fine needle aspiration cytology
o Excisional biopsy
Treatment
o NECK DISSECTION (radical or modified)
followed by radiotherapy
Neck Dissection classifications
COMPREHENSIVE NECK DISSECTION
CLASSICAL RADICAL NECK DISSECTION
EXTENDED RADICAL NECK DISSECTION
MODIFIED RADICAL NECK DISSECTION
TYPE 1 Selectively preserve the spinal accessory nerve
TYPE 2 Preserve the spinal accessory nerve and
sternocleidomastoid muscle
Sacrifice the internal jugular vein
TYPE 3 Preservation of all three structures
SELECTIVE NECK DISSECTION
o SUPRAOMOHYOID NECK DISSECTION

for oral cavity tumors; removes
levels 1,2 and 3
o ANTEROLATERAL NECK DISSECTION
(jugular neck dissection)

for laryngeal and thyroid cancers;
levels 2, 3, 4 and 6
o CENTRAL COMPARTMENT NECK
DISSECTION
o POSTEROLATERAL NECK DISSECTION

for posterior scalp tumors; levels
2, 3, 4 and 5
Parotid gland tumors
SALIVARY GLAND TUMORS Approximately 2/3 of malignant salivary tumor
OTHER CONSIDERATIONS
General considerations ROLE OF CHEMOTHERAPY in malignant head and
Major salivary glands (paired)
occur in the parotid
Most Parotid tumor are benign neck tumors
o Parotid glands Tumors more common in the superficial lobe o already established
o Submandibular glands Cranial nerve VII (facial nerve) o especially for goal of organ preservation
o Sublingual glands Treatment o Cell-targeted treatment
o Superficial parotidectomy even with
Minor salivary glands FUNCTIONAL END-RESULT / REHABILITATION
benign lesion
o Widely distributed in the mucosa of the o CN VII preservation is mandatory unless PAIN CONTROL
lips, cheeks, hard palate, uvula, floor of grossly involved by a malignant lesion
the mouth, tongue and peritonsillar o Ipsilateral neck dissection must be
region performed for clinically palpable nodes
Submandibular gland tumor
Clinically, the parotid gland is the most
important; most tumors of the salivary gland 10% of all malignant salivary gland tumors
lymph nodes are more commonly involved than
occur in the parotid
in parotid gland tumor
Tumors of the salivary glands 5% of all head
excision of malignant tumors entails performance
and neck tumors; affects the major glands 5x of supraomohyoid neck dissection
more often than the minor glands formal neck dissection in clinically positive nodes
Incidence of malignancy Minor salivary gland tumor
o Parotid tumors 25% Majority are mixed tumor
o Submandibular tumors 40% More than 50% are malignant
o Sublingual and minor gland tumors 70% Resection or radiotherapy depending on location
Since 70% of salivary gland tumors occur in the
parotid and three-fourths of these are benign,
the majority of salivary gland neoplasms are
benign
BENIGN
Pleomorphic adenoma (benign mixed tumor)
o Most frequent; mostly in females
middle aged
o 10% recurrence with surgery
Papillary cystadenoma lymphomatosus
(Warthins tumor)
o Mostly in males
o 10-15% bilateral
Hemangioma
o Most common salivary tumor in children
MALIGNANT
Malignant pleomorphic adenoma (mixed tumor)
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Papillary adenocarcinoma Rare
Epidermoid carcinoma
Acinic cell carcinoma rare
Lymphoma