Head and Neck Cancer

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Head and Neck Cancer
Enver Ozer, M.D. Head and Neck Oncology Department
of Otolaryngology

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Head and Neck Cancer

• 42,000 new cases U.S./year
• (6.6 of all malignancies )
• Squamous cell carcinoma gt 90
• Tobacco/alcohol association gt 90
• Survivallittle gain over past 30 years
• Mortality 50 over 5 years
• locoregional recurrence, distant metastases,
  2nd primaries, comorbid conditions

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Head and Neck CancerSites

• Upper aerodigestive tract
• oral cavity 30
• oropharynx
• larynx 30
• hypopharynx
• Face/scalp--cutaneous
• Nasal cavity/paranasal sinuses, nasopharynx
• Thyroid, salivary glands, lymph nodes

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Head and Neck CancerStaging

• TNM staging (tumor size, nodes, distant mets)
• Pretreatment clinical, radiographic information
• Specific criteria for each site (oral, pharynx,
  larynx)
• Stage I T1 N0 M0
• Stage II T2 N0 M0
• Stage III T3, N0, M0 or T1-3, N1, M0
• Stage IV any T4
• N2 or greater (node gt 3cm or multiple)
• M1 (distant metastases)

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Head and Neck Cancer

• Early stage (I, II) cure rates 70-90
• Single modality (surgery or radiation) often
  feasible
• Advanced stage (III, IV) cure rates 20-50
• Improved locoregional disease control
• Multimodality treatment
• Surgery
• Radiotherapy
• Chemotherapy
• Tradeofftoxicity
• High noncompliance/non completion
• Distant metastases, 2nd primaries, comorbidities
  remain problematicoverall survival unchanged

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Head and Neck Cancer

• Initial signs/symptomssubtle/absent
• Sore throat, hoarsenessresemble URI
• Persistence, constancy, progression ( gt 2wks)
• Dysphagia/weight loss, airway difficulty, neck
  massadvanced disease
• Cervical metastasessurvival reduced 50
• Single most predictive factor of survival
• Thorough evaluation, timely referral crucial

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Head and neck exam

• General appearance, respiratory effort, voice
  quality, symmetry, skin
• Inspect nasal cavity, auditory canals
• Oral cavity/pharynx lips, gums, dentition,
  cheeks, floor of mouth, tongue, tongue base,
  tonsillar fossa, palate, posterior wall
• Indirect exam larynx, hypopharynx, nasopharynx
• Cervical regions/nodes, thyroid, salivary glands
• Cranial nerve exam
• INSPECT and PALPATE

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Neck massDifferential diagnosis

• Children
• Inflammatory
• Congenital
• Malignancy
• Adults
• MALIGNANCY 80
• Persistent neck mass gt 2 weeks
• Inflammatory
• Congenital

80
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Neck massDifferential diagnosis
BENIGN
MALIGNANT

• Lymphadenitis
• Thyroglossal duct cyst
• Dermoid cyst
• Branchial cleft cyst
• Salivary gland
• thyroid

• Metastatic (SCCA, thyroid, salivary, distant)
• Lymphoma
• Salivary gland
• Thyroid

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Neck Mass

• Location - level
• Duration
• Size/progression, number nodes
• Mobility/fixation
• Character
• firm, cystic, pulsatile/bruit
• Contralateral status

Silver, 1996, 2nd ed
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Neck MassDiagnostic evaluation

• Thorough head and neck exam
• Inspect AND PALPATE
• Upper aerodigestive tractoral cavity, pharynx,
  larynx
• Face/scalp
• Salivary glands, thyroid

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Neck MassDiagnostic evaluation

• Imaging
• CT or MRI neck (usu contrast)
• CXR, ?CT chest
• ?PET scan

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Neck MassDiagnostic evaluation

• Fine needle aspiration biopsy
• need for open neck bx virtually eliminated
• high sensitivity, specificity
• experienced head and neck cytopathologist
• Avoid core/large gauge needle

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Neck MassDiagnostic evaluation

• Panendoscopy
• under general anesthesia
• direct laryngoscopy, nasopharyngoscopy,
  bronchoscopy, esophagoscopy
• directed biopsies, assess for occult primary
• Open biopsyAS A LAST RESORT
• FNA, directed biopsies negative
• Radical neck dissection if SCCA on frozen

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Unknown/occult primary

• lt 10 of metastatic neck masses
• if SCCA, presumed upper aerodigestive tract
  origin
• directed biopsies
• include tonsillectomy (20 occult primaries),
  tongue base, nasopharynx
• Treatment
• Radical neck dissection ( skin/scar if prior
  open bx)
• Definitive XRT (7000 cGy skull base to
  clavicles/upper mediastinum)
• Can contract treatment fields/boost primary if
  biopsies reveal primary location

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Neck DissectionTypes

• Comprehensive (levels I-V)
• N neck
• Radical
• sacrifice CN XI, IJV, SCM
• Modified radical, preserves
• Type I CN XI
• Type II CN XI, IJV
• Type III CN XI, IJV, SCM

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Neck DissectionTypes

• Selective dissection
• N0 neck for diagnostic/staging (N neckrole
  controversial)
• Highest risk levels dissected (depends upon
  primary site)
• supraomohyoid (I, II, III)
• lateral (II, III, IV)
• posterolateral (II, III, IV, V, posterior
  occipital)
• CN XI, IJV, SCM usu preserved

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Neck DissectionSentinel node procedures

• Melanoma, breast ca
• Theory
• Sentinel node predicts regional nodal status
• Guide to subsequent therapy (i.e. neck
  dissection, adjuvant rx)
• Role in H N SCCA yet undefined
• Technical challenges in HN
• multiple anatomic drainage sites
• access to primary for injection may be limited
• sites such as parotid gland require special
  attention
• primary site activity may obscure ID of nodes
• Limited series to date, NIH prospective trial
  ongoing

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Head and Neck CancerTreatment advances

• Functional preservation
• Functional restoration/rehabilitation
• Speech,
• Swallowing/mastication
• Respiration (without tracheostomy/stoma)
• Cosmesis

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Functional preservation

• Organ preservation approaches
• Non-surgical strategies
• radiotherapy, chemoradiotherapy
• preserve organ structure (indirectly function)
• Surgical strategies
• oncologic resection of clinical disease
• conservation techniques
• maintain organ function (speech, swallowing,
  respiration)

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Organ preservation strategies Nonsurgical
approaches

• Primary chemoradiotherapy
• Randomized trials for advanced disease
• larynx (VA cooperative), hypopharynx (EORTC)
• Survival similar to standard surgery radiation
• Significant laryngeal preservation
• Functional results variable
• Other sites (i.e. oropharynx)
• most data single arm phase I/II, institutional
• no randomized phase III trials to date or planned

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Organ preservation surgeryLarynx

• Endoscopic procedures (microscope)
• cold dissection
• CO2 laser

Weinstein, 1999
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(No Transcript)
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Leukoplakia

• White patch (oral, pharynx, larynx)
• Not a diagnosisdoes NOT suggest histology
• Requires biopsy
• esp if risk factors, persistent
• Risk of malignancy 10
• Erythroleukoplakia--red and white
• malignancy 50

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Organ preservation surgeryLarynx

• Open approaches-conservation laryngeal surgery
• vertical partial laryngectomy
• supraglottic laryngectomy
• supracricoid procedures
• Goals
• control disease
• maintain function

Weinstein, 1999
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Organ preservation surgeryLarynx

• Criteria for preservation surgery
• tumor extent
• functional status (pulmonary, exercise capacity)
• overall medical status (age, cardiac, diabetes)
• Predictable functional results
• Factors affecting postoperative function
• resection extent
• radiotherapy

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Organ preservation surgeryCranial base
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Organ preservation surgeryrobotic surgery
Arch Otol Dec 07
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Organ preservation surgeryrobotic surgery
Arch Otol Dec 07
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Restoration/rehabilitation of function

• Surgery/reconstruction
• Prosthedontic rehabilitation
• Speech/swallowing therapy

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Surgical reconstruction

• Grafts (skin, dermis, bone, cartilage)
• Local, regional flaps
• Free tissue transfer (vascularized)
• Adjunctive proceduresvocal rehabilitation
• Goals
• safe wound
• functional rehabilitation
• cosmesis
• single stage

Urken, 1995
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Free tissue transfer

• Variety donor sites
• Vascularized tissue
• epithelium, bone, muscle, nerve
• Complex defects
• mandible, tongue, pharynx, palate, skull base,
  orbit, face/neck
• Microvascular technique
• gt 95 success (flap survival)
• Drawback time-consuming, ?cost

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• Anterior mandible
• fibula, iliac crest free flap
• mastication, dentition
• support tongue, floor of mouth
• -speech, swallowing, airway
• chin projection

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Vocal rehabilitation/restoration

• Partial laryngectomy
• thyroplasty, speech therapy
• Total laryngectomy
• loss phonatory ability
• loss lung powered speech
• Options
• non verbal methods
• esophageal speech
• external devices
• tracheoesophageal speech

Silver, 1996, 2nd ed
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Tracheoesophageal Speech

• Restores phonatory capability
• Restores lung powered speech

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Rehabilitative adjuncts

• Prosthedontics
• adjunctive or primary
• functional--dentition, eating/swallowing, speech
• cosmetic

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Rehabilitative adjuncts

• Prosthedontics
• adjunctive or primary
• functional--dentition, eating/swallowing, speech
• cosmetic

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Head and Neck CancerMultidisciplinary Focus

• Head and Neck Surgeon
• Radiation Oncology
• Medical Oncology
• Internal Medicine
• Nursing
• Dentistry, Oromaxillofacial Surgery/Prosthedontics
  
• Speech Pathology
• Physical/Occupational Therapy
• Social Services
• Psychosocial Referral

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Head and Neck CancerFuture horizons

• Intensified therapy
• improve disease control
• reduce toxicity
• Targeted therapy/molecular therapy
• Adjuvant strategies
• Gene therapy (p53, ONYX-015)
• Antibodies/small molecules
• EGFR, VEGFR