Please enable JavaScript.
Coggle requires JavaScript to display documents.
Head and Neck Cancer (Laryngeal cancer (treatment (Advanced laryngeal…
Head and Neck Cancer
Laryngeal cancer
Supraglottis (55-60%)
- epiglottis, false cords, arytenoids, aryepiglottic folds
- Exophytic, fast growing, poorly differentiated tumors, frequent nodal metastases
Glottis (35-40%)
- vocal cords, ant commisure, post comissure
- well differentiated, less aggresive, unfrequent nodal metastases
Subglottis (5%)
- paratracheal nodes metastases
epidemiology
- Most prevalent head and neck cancer
- 5,1% cancer incidence in males, 0,7% in females
- Peak incidence 50-60 years
Symptoms
- persistent hoarseness --> glottis
- sore throat --> supraglottis
- earache --> supraglottis
- shortness of breath --> advanced exophytic tumor
- neck lymph node enlargement --> supraglottis, almost never glottis usually subdigastric node
diagnosis
- indirect, direct laryngoscopy.
- biopsy, histology
- CT, MRI --> staging.
- neck ultrasound
- chest X-ray
Neck nodes involvement
- Glottis – below 10%, Only when supraglottic invasion
- Supraglottis – 45% - 55%, 1st echelon – subdigastric nodes
treatment
Supraglottic cancer
- T1, T2 --> RT = horizontal supraglottic laryngectomy
- Large primary lesions --> total laryngectomy + adjuvant RT
- Stage III or IV --> larynx preservation protocols (chemoradiation)
Early laryngeal cancer
- Partial surgeries, Chordectomy, Horizontal supraglottic laryngectomy, Vertical partial laryngectomy
- Radical radiotherapy Dg=66-70 Gy
-
Treatment
-
goals
- Cancer eradication
- Organ preservation
- Acceptable cosmetic effects
- Small primary lesions (T1 i T2) univolved neck nodes (N0) --> One modality: surgery or radiotherapy
- Small primary lesions (T1 i T2) ivolved neck nodes (N+) --> Surgery + RT of the neck
- Large primary lesions (T3 i T4) or massive neck involvement – surgery + postoperative RT
Neck dissections
- Radical neck dissection (RND):
node levels I – V, SCM (sternocleidomastoid), IJV (internal jugular vein), XI cranial nerve
- Modified radical neck dissection (MRND):
preservation of one or more nonlymphatic structures
- Selective neck dissection (SND):
lymph nodes only dissection of all or selected levels
- Suprahyoid lymphadenectomy
removal of submental, submandibular, upper cervical lymph nodes and submandibular salivary gland
Radiotherapy
- high dose necessary to achieve success
- Standard doses: Subclinical lesions 50 Gy, Early stage (T1) 60 – 65 Gy, Intermediate stage (T2) 65 – 70 Gy, Advanced stage (T3 i T4) >70 Gy
Salivary gland cancer
- 75-85% tumors in parotid, 5-10% submandibular gland, only 1% in sublingual and minor salivary glands
- Only 10 % of parotid tumors are malignant (most – polymorpic adenomas)
- 50% of submandibular tumors and most sublingual and minor salivary glands tumors are malignant
-
Symptomatology
- Benign tumors: slow, expanding growth, without skin or nerve infiltration, no palsy
- Malignant tumors: infiltration of skin, vessels, cranial nerves, adjacent bones and muscles
- Edema or lump within the gland, skin erythema
- Facial nerve palsy
- Trismus and IX-XII nerve palsy
Diagnostic workout
- Inspection and palpation, Ultrasound, CT, Facial bones X-ray, Sialography, Chest X-ray, Blood tests
Treatment
- Parotid gland surgery (parotidectomy) superficial or total) with facial nerve preservation
- Adjuvant RT
indications: Positive operative margin, Neck lymph nodes involvement, Poor differentiation, Incomplete resection, Nerve infiltration or perineural spread, Adjacent soft tissues infiltration, Recurrent cancer after surgery
Nasopharyngeal cancer
-
-
-
treatment
- In II and III WHO type all stages but T1N0M0 require chemoradiation with DDP
- Possibly adjuvant chth 3 cycles of PF
- Highly advanced tumors – to consider neoadjuvant chth 2-3 cycles
- Type I WHO -->T1-T2N0 RT alone
T3, T4, or N1-3 chemoradiation
Oropharyngeal cancer
- 3x more prevalent in M
- Histology: SCC 95%, Minor salivary gland tumors, Lymphoepithelioma, Lymphoma (Waldeyer ring)
symptomatology
- Lump in the throat, Swallowing difficulties, Pain, Enlarged lymph nodes, Trismus – infiltration of pterygopalatine fossa, masseter muscle
Diagnosis
- Inspection and palpation, Laryngoscopy, flexible endoscopy
- CT, Chest X-ray, Blood tests
treatment
- Radical radiotherapy is a mainstay of therapy
- Surgery – neck lymph nodes removal if persistent 4-8 weeks after RT
Histopathology
- Squamous cell carcinoma – (Ca planoepitheliale) 90%
- Adenocarcinoma
- Transitional cell cancer
- Lymphoepithelioma
- Malignant lymphoma, melanoma
Precancerous lesions:
- Leukoplakia – (a white patch or plaque), malignant metaplasia 30%
- Erytroplakia - (a red patch), Malignant metaplasia 50%
- Hyperkeratosis - lip, Laryngeal papilloma, Pachyderma of larynx, Dysplasia
- Exophytic tumor - better prognisis
- Endophytic, infiltrating – aggresive
Hypopharyngeal cancer
Symptomatology
- Late and not typical symptoms
- Neck lymphadenopathy, Swallowing difficulties, Pain, frequently irradiating to the ear, Voice hoarseness, Shortnees of breath, cough
Diagnosis
- Inspection and palpation, Laryngoscopy, flexible endoscopy
- CT, Chest X-ray, Blood tests
Treatment
- Surgery (laryngopharyngectomy, lymphadenectomy) and adjuvant radiotherapy
- Inoperable locations (posterior oropharyngeal wall and postcricoid area) – radical RT, unconventional RT or concurrent chemoradiotherapy
Oral cavity cancer
Symptoms
- Lump or ulceration, Swallowing difficulties, Impairment of tongue mobility, Speech difficulties
- Pain, frequently irradiating to the ear
- Loose teeth, Lymphadenopathy
Diagnosis
- Inspection and palpation, Laryngoscopy, flexible endoscopy
- CT, Chest X-ray, Blood tests
treatment
- T1N0 – brachytherapy or local excision (surgery preferred if G1, tip of tongue or <0.5 cm to mandible)
- Other – mainstay of tx resection with reconstruction and lymphadenectomy + adjuvant RT
- Tumor > 3 cm, mandible infiltration and N+ - surgery indicated
Etiology
- Tobbaco smoking, alkohol (especially combined)
- Poor oral hygiene
- infections:
Epstein-Barr virus (EBV) nasopharyngeal cancer
HPV (type 16, 50% oral cavity cancers, SCC of nasal cavity and sinuses )
- Tobbaco chewing – oral cavity cancers
- Wood dust inhalation (carpenters, furniture industry) – nasal cavity cancers
- Chronic iron deficiency anemia (Plummera-Wilson syndrome) – tongue and postcricoid cancer
- Ionizing radiation exposure, esp. in childhood – thyroid cancer, salivary gland cancer
symptoms
- Oral cavity– edema, non-healing ulceration, pain (irradiating to the ear)
- Oropharynx – asymptomatic dysphagia, sore throat, odynophagia, otalgia, lump in the neck
- Hypopharynx - asymptomatic dysphagia, odynophagia, otalgia, lump in the neck
- Larynx – persistent hoarse, pain (irradiating to the ear), dyspnea, stridor
- Nasopharynx – initially asymptomatic
nasal bleeding (epistaxis), nasal obstruction, deafness, neurological symptoms of cranial nerves involvement, lump in the neck
- Nasal cavity and paranasal sinuses – epistaxis, nasal obstruction, facial pain and edema, double vision
- Salivary glands – tumor, edema, facial nerve palsy
treatment results
- Cure in < 50% (worst results – hypopharyngeal cancer 15-30% 5-y survival, best results early laryngeal and lip cancers– 90% 5-y survival)
- In general early stage 5-y survival 60-80%, locally advanced – 30 %
- Failures are usually loco-regional
Substantial impairment
Dysfunctions
Swallowing problems, Aphonia, Vision loss, Salivaryglands damage, Hearing loss
Deformations
Nose amputation, Partial mandibulectomy, Orbital exenteration
-
Epidemiology
- oral cavity > laryngeal > oro and hypopharyngeal > nasopharyngeal
- in males: larynx > lip > tongue > oropharynx
- in female: that same
Diagnostic workout
- Anamnesis, physical examination, especially:
- Laryngological examination
- Endoscopy (flexible)
- Biopsy (FNA, excisional)
- Radiology: CT, MRI, chest X-ray, bone scan, PET (unknown primary)
Cancer of the lip
- characterized by slow growth, late lymph node metastases
- well differentiated cancer
- Treatment:
early lesions: resection or brachytherapy
advanced lesions: wide resection with reconstruction and adjuvant radiation or definitive radiotherapy