DIAGNOSIS AND TREATMENT OPTIONS IN HEAD AND NECK NEOPLASMS

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DIAGNOSIS AND TREATMENT OPTIONS IN HEAD AND NECK
NEOPLASMS

• EVAN S. BATES, M.D.
• DEPT. OF OTOLARYNGOLOGY

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NASAL/SINUS TUMORS

• Overall incidence 1100,000
• 80 SCCA, 10 ACC/AC
• Risk factors environmental exposure
• Diagnosis
• CT/MRI, biopsy
• Treatment
• Surgical resection
• Chemotx/XRT

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CASE PRESENTATION
This 37 yo male presented with a 4-5 week H/O an
enlarging left neck mass. 3 months earlier he
noted episodes of left nasal congestion with eye
discomfort. PMH ASD repair 3/96 H/O
smoking 1ppd/15 yr., quit 5 yr. go Exam
nasal polypoid mucosa left inf.turbinate
oropharynx nl. neck 6 x 5 cm firm, mid.
Cervical mass
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EVALUATION

• FNAB
• for malignant cells
• immunostain profile suggests medullary CA
• MRI
• large left neck mass, adenopathy in levels 2-4,
  small left intraparotid masses. Thyroid nl.
• CXR nl.
• Laboratory
• calcitonin 2, CEA lt0.7, TSH, LFTs nl.

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DIFFERENTIAL DIAGNOSIS

• Lymphoma
• Primary salivary neoplasm
• mucoepidermoid CA, squamous CA, adenoCA
• Thyroid neoplasm
• anaplastic CA, medullary CA
• Sinus neoplasm
• squamous CA, adenoCA
• Unknown Head Neck Primary

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SURGICAL MANAGEMENT

• Left radical neck dissection
• Left total parotidectomy

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SURGICAL FINDINGS

• Normal thyroid gland
• Multiple parotid cysts
• Large left neck mass w/ additional adenopathy
• Frozen section
• c/w malignant neoplasm
• Permanent section
• c/w rhabdomyosarcoma, alveolar type

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SURGICAL MANAGEMENT

• Left endoscopic turbinectomy, resection of nasal
  mass
• findings
• large polypoid mass on posterior inf. Turbinate
  with extension superiorly along lateral nasal
  wall to middle meatus
• path
• rhabdomyosarcoma

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RHABDOMYOSARCOMA MD ANDERSON EXPERIENCE

• 5 yr. Survival 44, 60 w/combined TX.
• Poor survival
• adult onset of disease
• alveolar histology-distant mets
• Symptoms
• nasal obstruction (60), facial pain (41),
  facial swelling (38), proptosis (35), epistaxis
  (27)

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RHABDOMYOSARCOMA UCLA EXPERIENCE

• Orbit (35), Maxillary sinus (15)
• 35 had CNS extension from sinus/orbit
• Histology not a factor in prognosis
• Overall survival 34
• Trend toward conventional surgery followed by
  intensive chemo/XRT

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RHABDOMYOSARCOMA

• Most common headneck tumor in children, rare in
  adults
• 69 advanced _at_ presentation (Group III,IV)
• Ethmoid sinus most common site (46)
• Nodal mets (46), systemic mets(26)
• Management chemo/XRT/surgery
• 7.6 5 yr. survival

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NOSE EXAMINATION
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NASAL POLYPS

• Usually seen in chronic sinusitis or chronic
  allergy patients
• Topical corticosteroids of minimal benefit
• Polyps require sugical excision and biopsy
  followed by long term allergy management

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OROPHARYNGEAL CARCINOMA

• Usually presents with painful oral ulcer
• Adult males 50-70 yrs. old
• Risk factors smoking, ETOH
• Majority of tumors SCCA, lymphoma
• Management
• Surgery/XRT
• XRT/CHemotx

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TONSILLAR CARCINOMA

• 20-30 present with neck metastases
• Evaluation with CT/MRI, Chest CT, PET scan, LFTs
• Management must include neck disease
• Stage I survival 80-90, Stage IV survival 25-40
• Treatment standard involves surgery/XRT

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TONGUE NEOPLASMS

• 3 of all CA in US, 50 of CA in India, 3rd most
  common malignancy in France
• gt90 SCCA, associated with tobacco use, ETOH
• Survival rate decreased with lymphatic
  involvement
• Treatment focused on surgery/XRT
• Reconstruction of prime importance

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TONGUE CARCINOMA

• Tongue lesions can be resected primarily due to
  tongue redundancy
• Primary closure vs. local flap
• XRT for incomplete resection, T2 or greater
  lesions or nodal disease

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TONGUE MASS

• Neurofibroma
• Mucosal covered mass rather than ulcerated lesion
• Surgical resection alone is sufficient

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NECK EXAMINATION
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NECK MASSES

• KEY TO DIAGNOSIS IS HISTORY
• TIME COURSE OF MASS
• PAINFUL/TENDER
• RECENT INFECTIONS/TRAUMA
• SMOKER?
• PHYSICAL EXAM
• LOCATION OF MASS
• FIRM/CYSTIC/TENDER/MULTIPLE MASSES

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NECK MASSES

• IF YOU SUSPECT INFECTION, TREAT WITH 1 COURSE OF
  ANTIBIOTICS
• IF NO RESOLUTION, REFER TO ENT
• EVALUATION
• HEAD NECK EXAM
• FNA-B
• CT/MRI

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NECK EXAMINATION
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THYROID MASS

• Large thyroid mass suspicious for malignancy
• FNA-B important
• Surgical resection with CN X monitor
• Post-operative therapy dependent on path

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LIP CARCINOMA

• Uncommon site for oral carcinoma
• Usually managed with wide local excision
• Frequently seen in pipe smokers

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HOARSENESS

• MANAGEMENT
• REFER TO ENT IF PROLONGED OR DIAGNOSIS UNCERTAIN
• INDIRECT LARYNGOSCOPY
• BE SUSPICIOUS OF MALIGNANCY IN SMOKERS AT ANY AGE

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LARYNGEAL CARCINOMA

• Usually seen in smokers
• Extremely hoarse voice for several weeks
• May have referred otalgia
• Obviously needs laryngoscopy/biopsy

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LARYNGEAL CARCINOMA

• Treatment goals shifted to larynx preservation
  based on 1992 VA study
• 11,000 new cases annually, gt90 have smoking
  exposure
• Induction chemotx/XRT preserves larynx in 64
  patients
• XRT for T1/T2 lesions
• 5 yr. Survival 70-80 for T3lt lesions, 40 for T4
  lesions

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LARYNX EVALUATION
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VOCAL CORD NODULE

• Usually a gravelly/hoarse voice
• History of voice overuse/singers
• Voice rest may help
• Often associated with GERD
• ENT eval. for laryngoscopy

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HOARSENESS

• ASSOCIATED WITH URI
• SELF-LIMITED
• RESOLVES IN 7-21 DAYS
• PROLONGED RESOLUTION IN SMOKERS
• MANAGEMENT
• ANTIBIOTICS (S. AUREUS)
• HUMIDIFICATION
• STEROIDS

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HOARSENESS

• CHRONIC HOARSENESS
• VOCAL OVERUSE
• VOCAL FOLD POLYPS
• GERD
• PRESBYLARYNGIS
• ACUTE HOARSENESS
• IF ASSOCIATED WITH NECK TRAUMA--ER