Head and Neck Cancer Surgery of the Oral Cavity

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A Practical Guide to Head and Neck
CancerDiagnosis and Treatment
Symposium on Cancer Care Kitchener-Waterloo
November 7, 2008

• John Yoo MD, FRCS(C), FACS
• Chairman and City-wide Chief
• Department of Otolaryngology
• Director of Head and Neck Oncology
  Reconstructive Surgery
• Schulich School of Medicine Dentistry
• University of Western Ontario

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Case 1

• 48 year old man
• Smoker
• Lesion on tongue
• Present for 4 months
• Not painful
• No other symptoms

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Case 2

• 64 year old man
• Non-smoker, social EtOH
• Painless, enlarging neck mass 3 months

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Case 3

• 72 year old woman
• Enlarging mass right upper neck
• 6 months

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Case 3 Contd

• 3 month later
• Involvement of skin
• Remote history of skin cancer left scalp

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Contents

• 1. Scope heterogeneous group of diseases
• a) HN mucosal cancers
• b) Salivary gland tumours
• c) Thyroid (and parathyroid)
• c) Skin cancer
• 2. Background
• 3. Neck Mass
• 4. Salivary gland
• 5. Mucosal Cancer

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Worldview

• Head and Neck Cancers uncommon in Canada
• Worldwide oral pharyngeal cancer 6th most
  common cancer
• 2/3 of cases in developing countries.
• Highest rates in South Asia--Indian sub-continent
  1/3 of world burden.
• Incidence mortality from oral cancer is rising
  in regions of Europe, Taiwan, Japan and
  Australia.

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Function of HN Critical to QoL

• Anatomy function complex.
• Coordinated breathing, chewing swallowing,
  speech.
• Organ preservation usually important goal of
  cancer treatment.
• Cancer death most often due to complications of
  local recurrence.

Local Control is the Goal!
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Risk Factors and Associations

• Smoking
• Alcohol
• Ethnicity
• Dietary factors
• Viruses
• Asbestos
• Occupation
• HPV 16

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Clinical Presentation

• Neck Mass
• Local Signs and Symptoms

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The Neck Mass

• Understanding Head and Neck Pathology is to
  understand the neck
• 1. Anatomy
• 2. Lymphatics

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Head and Neck AnatomyThe Language of Nodes

• Boundaries of the Neck
• The neck is a square with a diagonal line drawn
  through it.
• 1. Top Jaw
• 2. Bottom Clavicle
• 3. Back Trapezius
• 4. Front Midline
• 5. Diagonal Sternomastoid

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Head and Neck Anatomy

• The Parotid Region
• The parotid gland is located at the side of the
  face and extends below the jaw
• It is a structure of the upper neck

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Head and Neck Anatomy

• The Submandibular Triangle
• 1. Mandible
• 2. Anterior belly of digastric m.
• 3. Posterior belly of digastric m.

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Lymphatic Drainage

• drain along the veins
• drains to the most logical place and next level
  downstream
• all roads lead to the deep chain and into the
  chest

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Practical Approach to the Neck Mass

• 1. Location of the mass
• 2. Age of the mass
• 3. Age of the patient

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Location of Neck Mass

• Midline vs Lateral

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The Midline Mass Between the SCM muscles

• Its a thyroid thing
• 1. Thyroid goitre
• 2. Thyroid tumour
• 3. Thyroglossal duct cyst

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Midline Mass

• Others
• 1. Dermoid cyst
• 2. Laryngocele
• 3. Lymphatic malformation
• 4. Zenkers Diverticulum
• 5. Lymph node

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Lateral Neck Mass
Differential Diagnosis

• Normal structure
• Neoplastic
• 2. Inflammatory/Infectious
• 3. Congenital
• 4. Other

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The Normal Neck Mass

• 1. Submandibular gland
• 2. Transverse process C-2
• 3. Carotid bulb
• 4. SCM muscle
• 5. Hyoid bone
• 6. Cervical rib

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The Rule of 7s

• 7 days infection
• 7 mths neoplasm
• 7 years congenital

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The Age Rule

• lt 20 years
• Inflam gt Congen gt Neoplastic
• gt 40 years
• Neoplastic gt Inflam gt Congen

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Adult 80 Rule

• 80 neoplastic
• 80 malignant
• 80 metastatic
• 80 primary above clavicles
  

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Age Rule 80 Rule

• In the elderly patient, a lateral neck mass
  is a cancer until proven otherwise.

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Diagnosis

• History and Physical Examination
• 1. Patient factors
• 2. Disease factors
• Investigations
• 1. FNAB (fine needle aspiration biopsy)
• 2. Imaging
• 3. Others

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Management

• The diagnosis can be established in the vast
  majority of patients based on clinical assessment
  alone.
• The open neck biopsy is the test of last resort
  and should be avoided prior to definitive
  treatment.

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Salivary Gland Tumours
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Salivary Gland Tumours

• My favourite tumour
• Always surgical
• Very technical
• Each is a unique challenges
• Excellent long-term survival
• Quality of operation completely determines
  patient outcome.

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Likelihood of cancer in a salivary mass

• Parotid Gland 25 malignant
• Submandibular 50
• Others 75

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Salivary Gland Tumours
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Base of Tonge
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Management

• Mass arising within the salivary gland should be
  removed.
• Removal is both diagnosis and treatment

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Benign Tumours

• Benign tumours almost always require removal
• 1. Confirm diagnosis
• 2. Continued growth
• 3. Malignant transformation
• 4. Symptom relief

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Boundaries of the parotid gland

• Any mass within these boundaries should be
  considered a parotid tumour
• Superior Zygomatic arch
• Inferior Jaw line
• Anterior Lateral canthal line
• Posterior Mastoid process
• Lateral Skin
• Medial Tonsillar fossa

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Head and Neck CancerSite Specific Presentation

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Disease Sites

• 1. Oral Cavity and Oropharynx
• 2. Larynx and Hypopharynx
• 3. Nasopharynx
• 4. Nose and Paranasal Sinuses
• 5. Unknown Primary (PUK)

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Oral Cavity
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Larynx
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The dilemma

• Majority of upper Aerodigestive Tract Mucosa is
  not visible for direct examination
• Half the patients presents with no obvious signs

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The Pharynx

• Clinical presentation
• 1. Dysphagia / odynophagia
• 2. Foreign body sensation
• 3. Referred otalgia
• 4. Hoarseness
• 5. Breathing trouble
• 6. Neck mass
• 7. Systemic symptoms

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Clinical Evaluation

• History and P/E
• Office-based endoscopic examination
• FNA biopsy
• Tissue biopsy
• CT scan (HNC)

• Note
• in most instances, treatment plan can be
  established on initial visit

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Treatment Modalities in Head and Neck Oncology

• 1. Surgery
• 2. Radiation Therapy
• 3. Chemotherapy

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Head and Neck Multidisciplinary Tumour Board

• Radiation Oncologist
• J Hammond
• N Read
• V Venkatesan
• Head and Neck Surgeons
• J Franklin
• K Fung
• J Yoo

• Medical Oncologist
• S Ernst
• E Winquist
• Nurse Specialists
• Dentistry
• SLP
• Dietitian
• Social worker
• Physiotherapist

Team approach to patient care
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Treatment Concepts

• Early Disease single modality
• 1. Surgery
• 2. Radiation
• Advanced Disease multimodality
• 1. Surgery Chemo/Radiation
• 2. Chemotherapy Radiation

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Prognosis

• Survival Rates
• Overall gt 50 cure
• 75 cure in early
  disease
• 25 cure in late
  disease

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Oral Cavity
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Function of HN Critical to QoL

• Anatomy function complex.
• Coordinated breathing, chewing swallowing,
  speech.
• A little bit of anatomy spared goes a long way
• Cancer death most often due to complications of
  local recurrence.

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Surgical Dilemma
Preserve anatomy
Complete resection

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Prognosis

• Cancer related mortality
• gt 80 die from local or regional relapse
• lt 20 die from distant disease

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Reconstruction

• The importance of providing a quality
  reconstruction

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The Need for Rigorous Reconstruction

• Function
• Speech
• Swallowing
• Breathing
• Form
• Aesthetics
• Protection
• Brain
• Major vessels
• Fundamentally alters the way patients see
  themselves and how other see them.

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Protecting the brain and complex contouring
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Conclusion

• Early detection and treatment is critical
• Local and regional disease control is most
  important factor for patient outcome.
• Functional considerations are important in
  deciding treatment modality and reconstruction
• Diagnosis and treatment plan is usually possible
  at initial visit