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Head and Neck Cancer

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Title: Head and Neck Cancer


1
Head and Neck Cancer
  • Radiation Therapy 4412

2
Management of Head and Neck Cancer
  • Through multidisciplinary treatment we try to
  • 1. decrease deformity
  • 2. maintain the reduction of the tumor
  • 3. restore function
  • 4. preserve the structure and esthetics
  • 5. cure the cancer

3
1. Compare and contrast the epidemiologic factors
prevalent in head and neck cancers
  • 1/3 of patients that are treated have early stage
  • 2/3 of patients will have locally advanced stages
  • Lungs are the most common site for mets
  • The nerve routes are important in treatment
    planning, tumors can spread this way

4
  • Almost half of all squamous cell ca occur in the
    oral cavity
  • Head and neck cancer involves the upper
    aerodigestive tract.
  • Oral cavity
  • Pharynx
  • Paranasal sinuses
  • Larynx
  • Thyroid gland
  • Salivary glands

5
  • Men- usually 50-60 years old
  • Can occur in people younger than 40 years of age
  • More women are smoking
  • Smokeless tobacco
  • Recurrences- usually within first 2 years
  • Rarely after 4 years
  • Most 5 year survivors will be alive at 10 years

6
2. List and describe the etiologic factors
associated with head and neck cancers
  • Smokeless tobacco- squamous cell of cheek and gum
  • Previous radiation exposure- thyroid /salivary
    glands
  • Poor oral hygiene
  • Ill fitting dentures/irritation to tissues

7
  • Wood mill workers- nasal cavity/paranasal sinuses
  • Lip cancer- UV exposure, unfiltered cigarettes
  • Viruses
  • Epstein Barr virus
  • Herpes simplex (cold sores)
  • HPV- oral/larynx
  • Chronic abuse of marijuana- degree of risk
    unknown
  • Diet
  • Vitamin A and E deficiency
  • Plummer-Vinson syndrome- iron deficiency anemia

8
  • Alcohol
  • Pharyngeal and laryngeal cancer
  • Liver damage
  • Secondary nutritional deficiencies
  • Alcohol damages mucosa and makes it more
    permeable
  • Impurities in the alcoholic beverages

9
  • Smoking
  • Head and neck cancers occur 6x more frequently
    than non-smokers
  • Unfiltered cigarettes
  • Cigar smoking is a risk
  • Laryngeal cancer mortality increases as the
    number of cigarettes smoked increases

10
Smoking, tobacco, alcohol a deadly combination!
  • Alcohol is synergistic to tobacco- cooperate
    together to produce a total effect greater than
    the sum of the individual elements
  • Tars
  • Aromatic hydrocarbons
  • Ethanol suppresses the efficiency of DNA repair
  • Nitrosamines most noncombustible product in snuff
    and chewing tobacco

11
  • Pre-cancerous signs
  • Leukoplakia is a precancerous, slowly developing
    change in the mucous membrane. They are
    characterized by thickened, white, firmly
    attached patches that are slightly raised.
  • Erythroplasia- A premalignant lesion that is
    shiny, velvety and reddish in color
  • These are severe dysplastic changes and should be
    taken seriously

12
Leukoplakia
13
3. Identify the prognostic indicators in head and
neck cancers
  • Prognosis decreases as
  • The affected area progresses backward from the
    lips to the hypopharynx (excludes larynx)
  • Lesions that cross the midline
  • Exhibits endophytic growth- invades within the
    lamina propria and submucosa
  • Have cranial nerve involvement
  • Fixed nodes

14
  • Fixed lesion in the anatomic compartments
  • Are poorly differentiated
  • Nonsquamous cell

15
5. Compare and contrast endophytic and exophytic
tumor features of head and neck cancers
  • Endophytic growth- growth pattern that invades
    the lamina propria and submucosa
  • -more aggressive and harder to control locally
  • Exophytic- a noninvasive neoplasm that projects
    out from an epithelial surface
  • -characterized by raised, elevated borders
  • Most head and neck cancers are infiltrative
    lesions found in the epithelial lining

16
Staging
  • Lymphatics of the head and neck are in direct
    correlation to the prognosis
  • 1/3 of the bodys lymphatics are in the head and
    neck area
  • Staging depends on
  • Site of primary disease
  • Extent of primary disease
  • Size of primary tumor

17
  • Staging contd
  • Cell type and differentiation
  • Lymphatic vascular space invasion of the tumor
  • The nodal status

18
6. List and describe the different types of head
and neck cancers
  • Most head and neck cancers will infiltrate into
    the epithelial lining of the upper digestive
    tract
  • 80 of all head and neck cancers will be squamous
    cell

19
7. Compare and describe the different types of
head and neck cancers.8. Describe the different
treatmentconsiderations for the different types
of head and neck cancers.
20
Oral Cavity
  • Oral cavity extends from the skin vermilion
    junction of the lip to the posterior border of
    the hard palate superiorly
  • And the circumvallate papillae inferiorly
  • Anterior 2/3 of the tongue lips, buccal mucosa,
    lower alveolar ridge, upper alveolar ridge,
    retromolar trigone, floor of the mouth, and hard
    palate
  • Page 694 Washington/Leaver

21
  • Oral cavity cancers
  • The most common aerodigestive tract cancers
  • Occur mostly in men- 55 to 65 years old
  • Alcohol and tobacco are synergistic
  • Patients usually have poor oral and dental
    hygiene
  • Plummer-Vinson syndrome is important etiologic
    factor

22
  • General practitioner or dentist will find the
    cancer
  • Early diagnosis is important
  • Leukoplakia and erythroplasia are serious
  • Most oral cavity cancers will be nonhealing
    ulcers with little pain
  • Localized pain is an advanced disease

23
  • The cancer is usually raised, centrally
    ulcerated, indurated edges and the base is
    infiltrating
  • Mandatory biopsy
  • Squamous cell carcinoma makes up 90-95
  • Well or moderately well differentiated
  • Has the lowest incidence (except glottic) of
    nodal mets
  • Cervical node involvementadvanced disease

24
Lips and Gum
  • Lip cancer is treated with radiation the same way
    as skin cancer
  • Usually involves the lower lip and spreads by
    direct invasion
  • Carcinoma in-situ and early lesions of the lip
    may be surgically removed

25
  • Radiation Therapy
  • Portal should include primary lesion with a 2 cm
  • A shield (stent) of lead and bolus material (to
    absorb backscatter) is placed under the lip
  • This blocks the alveolar process and gums
  • Treated with external beam, interstitial implant
    or both
  • 100 SSD, 100 isodose line

26
Lip Cancer
27
Floor of Mouth
  • Floor of the mouth lesions usually arise on the
    anterior surface on either side of the midline.
  • They can spread to bone and tongue
  • Approx 30 of these cancers will involve the
    submaxillary and subdigastric nodes
  • Opposed lateral fields are used
  • The tip of the tongue can be elevated out of the
    portal with a cork or a bite block and tongue
    depressor

28
  • Bite blocks can also spare the roof of the mouth
    from incidental irradiation
  • If the lesion has grown into the tongue, the
    tongue is flattened to reduce the superior border
    of the portal
  • Radiation therapy supraclavicular and bilateral
    neck fields, followed with a boost of intraoral
    cone, needle implants, or small external photon
    beams

29
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30
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31
Tongue
  • The anterior 2/3 of the tongue is included in the
    oral cavity
  • The base of the tongue is considered oropharynx
  • Small tumors in the anterior 2/3 of the oral
    tongue are usually resected
  • Radiation therapy is used for inoperable patients

32
  • Post-op radiation therapy
  • Treats the primary site
  • Treats the cervical lymph nodes
  • And margins positive
  • for tumor,
  • extensive primary tumor with bone or skin
    invasion,
  • and multiple positive nodes

33
  • The anterior tongue drains into the
  • Submandibular lymph nodes
  • The posterior portion of the tongue drains into
    the
  • Jugulodigastric
  • Posterior pharyngeal
  • Upper cervical lymph nodes
  • Lesions of the tongue usually appear on the
    lateral borders near the middle and posterior
    third section
  • A limited number of tongue cancers can be excised
  • Most are controlled with external beam and
    interstitial boost fields

34
  • Lesions at the base and posterior 1/3 of the
    tongue invade
  • The floor of the mouth
  • Tonsils
  • or the muscles
  • Are advanced
  • Have a higher incidence of nodal mets

35
  • Hemiglossectomy- surgical removal of half the
    tongue. It is used for treatment of an early
    stage lesion of the tongue
  • Radiation therapy- three field technique
  • Utilizes external beam, electron beam
  • Possibly an iridium implant and neck dissection
  • Isocentric lateral opposed fields
  • Lower anterior neck field
  • Fields include subdigastric and submaxillary
    nodes
  • Upper cervical nodes

36
T1 Squamous cell of tongue
37
Buccal Mucosa
  • Buccal mucosa is the mucous membrane lining the
    inner surface of the cheeks and lips
  • Most lesions arise on the lateral walls
  • Have a history of leukoplakia
  • Are raised, exophytic growths
  • Lesion invades the skin and bone
  • First sign is a bump on the tip of the tongue
  • No pain associated at first until the nerves to
    the tongue or ear become involved
  • Advanced lesions will bleed

38
  • Stensens duct (parotid duct) can become
    obstructed
  • The parotid gland becomes enlarged
  • Small lesions are surgically removed
  • Large lesions are treated with surgery and
    radiation therapy or
  • Radiation therapy alone
  • Complications- fibrosis of the cheek and trismus

39
Hard Palate
  • Located between the upper alveolar ridge and
    mucous membrane covering the palatine process of
    the maxillary palatine bones
  • Mostly adenocarcinomas and rare
  • Spread to the bone, invade the maxillary antrum
  • Treatment- surgical resection, post-op radiation
    therapy
  • History of ill fitting dentures or trauma

40
Retromolar Trigone
  • Triangular space behind the last molar tooth
  • Rare carcinomas
  • Symptoms- tongue, ear canal pain, trismus
  • Usually moderately differentiated squamous cell
    carcinoma
  • Lymphatic spread to the submaxillary
    subdigastric nodes
  • Treated with radiation therapy

41
PHARYNX
  • Subdivided into three anatomic divisions
  • Oropharynx
  • Nasopharynx
  • hypopharynx
  • Common symptoms
  • Persistant sore throat
  • Painful swallowing
  • Referred otalgia
  • Cervical node enlargement
  • Fetor oris, dyspnea, dysphasia, hoarseness,
    dysarthria, hypersalivation indicates advanced
    disease

42
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43
  • Diagnosis- indirect mirror exam, palpation,
    biopsy, CT, MRI
  • Histopathology- squamous cell carcinomas
  • Staging- AJCC Classification
  • Mets- cervical lymph nodes (bilateral),
    retropharyngeal nodes, lung

44
Oropharynx
  • Consists of the base of the tongue, the tonsils
    (fossa and pillars), soft palate, oropharyngeal
    walls
  • The oropharynx is located between the axis and C3
    vertebral bodies
  • Soft tissue regions- anterior tonsillary pillars,
    soft palate, uvula, base of the tongue and the
    lateral-posterior pharyngeal walls

45
  • Tonsils are the most common site for disease
  • Symptoms- sore throat and pain during swallowing
  • Upper spinal accessory nodes are involved
    bilaterally in 50 to 70 of the patients
  • Radiation therapy is treatment of choice

46
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47
Cancer of tongue
48
Hypopharynx
  • Pyriform sinuses, postcricoid, and lower
    posterior pharyngeal walls below the base of the
    tongue
  • It is situated between C3 to C6
  • The cricoid cartilage is the inferior border
  • Epiglottis is the superior border
  • Hypopharyngeal cancer is advanced
  • High rate of nodal mets

49
  • Tumor is highly infiltrative
  • The highest area for incidence is the pyriform
    sinus
  • Radical surgery and radiation therapy is the
    treatment of choice
  • Rouvieres (lateral retropharyngeal) lymph nodes
    at the base of the skull are included with other
    nodal groups in treatment (page 706, Washington)

50
  • Tonsillar, pharyngeal wall and posterior cricoid
    are treated using radiation therapy
  • (page 709, figure 30-28, Washington)

51
Unresectible T4 pyriform sinus tumor, surrounding
carotid artery
52
Nasopharynx
  • Posterosuperior pharyngeal wall and lateral
    pharyngeal wall, the eustachian tube orifice and
    adenoids
  • The nasopharynx is a cuboidal structure lying on
    a line from the zygomatic arch to the external
    auditory meatus (EAM), extending inferiorly to
    the mastoid tip
  • The nasopharynx lies behind the nasal cavities
    and above the level of the soft palate

53
  • The nasal cavity drains into the nsopharynx via
    the two posterior nares
  • Two eustachian tubes are on the lateral walls
    which connect to the middle ear
  • Nasopharyngeal disease can mimic an inflammatory
    process
  • Can cause considerable respiratory or auditory
    dysfunction

54
  • The cranial nerve is frequently involved
  • The ninth to the twelfth cranial nerves can be
    affected
  • Enlargement of the retropharyngeal nodes
  • Can affect the external carotid artery
  • A lesion can invade directly into the third
    cranial nerve
  • Commonly involves the sixth cranial nerve

55
  • When cranial nerves are involved, this means the
    disease is advanced and widespread
  • Histology- squamous cell
  • Nasopharyngeal cancer is usually poorly
    differentiated and shows an unusual growth
    pattern
  • This disease is not associated with tobacco
    consumption

56
  • NPC is associated with the Epstein Barr virus
  • Can occur in adolescence and young adults
  • Occurs again between 50 and 70 years of age
  • Uncommon in white populations
  • Found mostly in southern China and the Middle East

57
  • Positive cervical nodes in 75 to 85 of NPC
    patients
  • About half of all cases will have bilateral or
    contralateral disease
  • Radiation ports are large
  • The lateral retropharyngeal (node of Rouviere)
    which cannot be surgically removed, and
    jugulodigastric nodes are almost always treated

58
  • Primary lesion is small but the nodal disease is
    extensive
  • Bone and lung common mets sites
  • NPC spreads to adjacent sites and has a high
    recurrence rate
  • Aggressive, large volume curative radiation
    therapy is given

59
Larynx
  • The larynx is contiguous with the lower portion
    of the pharynx above and is connected with the
    trachea below.
  • It extends from the tip of the epiglottis at the
    level of the lower border of the C3 vertebra to
    the lower border of the cricoid cartilage at the
    level of C6

60
  • There are 3 main parts to the larynx.  These
    parts are
  • The supraglottis - the area above the vocal cords
    that contains the epiglottis cartilage    
  • The glottis - the area around the vocal cords   
  • The subglottis - the part below the vocal
    cords, containing the cricoid cartilage.  It
    continues down into the windpipe

61
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62
  • Glottic cancer- 65
  • Supraglottic cancer- 25 to 33
  • Subglottic- make up the rest of the cases
  • Most common cancer in the aerodigestive tract is
    the larynx
  • Male dominated disease
  • 50-60 years of age
  • Smoking high risk factor

63
  • Extensive use of voice in occupation is risk
    factor (singers, auctioneer) for laryngeal cancer
  • Alcohol high risk factor for supraglottic cancer
  • Cancer of the glottis (true vocal cord) is not
    life threatening
  • Choice of treatment is based on the preservation
    of speech and airway

64
  • Laryngeal cancer shows a mutation of the p53 gene
  • Classic Symptoms- persistent sore throat and
    hoarseness
  • Cervical lymph nodes involvement is associated
    with supraglottic lesions
  • Carcinoma in situ is common on the vocal cords

65
  • Glottic lesions are well to moderately
    differentiated
  • Supraglottic lesions are less differentiated and
    more aggressive
  • Glottic lesions will appear of the anterior 2/3
    of one cord (approx 65-75)
  • Cord mobility is a factor in the classification
    of lesions

66
  • Treatment- radiation therapy is the treatment of
    choice for nonfixed surface glottic lesions that
    have not invaded muscle, bone or cartilage
  • Glottic cancer is treated with lateral opposing
    fields 5X5cm or 6X6 cm
  • Large, fixed lesions will require aggressive
    treatment
  • Radiation therapy offers the best voice
    preservation

67
  • Supraglottic lesions are usually large and bulky
  • They do not usually invade the inferior false
    cord or the ventricles
  • These lesions usually spread superiorly to the
    epiglottis
  • Lymph nodes are usually involved in 40-50 of
    the patients

68
  • Subglottic lesions are treated with total
    laryngectomy with
  • Post-op radiation therapy

69
Larynx- squamous cell, Rt anterior vocal fold
70
Salivary Glands
  • Salivary glands are made up of
  • Parotid-largest gland, located superficial to and
    partly behind the ramus of the mandible, and
    covers the masseter muscle
  • It fills the space between the ramus of the
    mandible and the anterior border of the
    sternocleidomastoid muscle
  • Contains extensive lymphatic capillary plexus
    many aggregates of lymphocytic cells
  • Numerous intraglandular lymph nodes in the
    superficial lobe

71
  • Submandibular glands
  • Sublingual glands
  • Tumors of the salivary gland are rare
  • The parotid is the most common site for tumors
  • Nearly 2/3 of these tumors will be benign
  • Low-dose ionizing radiation in childhood may have
    been a risk factor
  • Dental x-rays have been implicated for both
    benign and malignant tumors

72
  • Most major and minor salivary gland cancers are
    of unknown origin
  • Adenoid cystic, mucoepidermoid, and
    adenocarcinoma are the most common cell types
  • Symptoms- asymptomatic parotid mass lasting 4-8
    months before the tumor arises
  • Presenting symptoms- localized swelling and pain,
    facial palsy, rapid growth
  • Facial nerve involvement suggests malignancy
  • Diagnosis is done through lobectomy

73
  • Treatment- Although most tumors are benign, local
    recurrence is high
  • Total resection with margins sparing facial
    nerves
  • Radiation therapy- post-op for residual,
    recurrent or inoperable tumors
  • Accelerated fractionation- provides similar dose
    levels of radiation therapy in a shorter amount
    of overall time. This counteracts quick cellular
    proliferation of aggressive tumors by giving more
    dose in a shorter period of time.

74
Maxillary Sinus
  • Maxillary sinus is a pyramid shaped cavity lined
    by ciliated epithelium and bound by thin bone or
    membranous partitions.
  • Carcinomas arising from the ciliated epithelium
    or mucous glands perforate the bony walls almost
    from the beginning
  • Tumors will also involve the superior portion of
    the sinus and extend into the floor of the orbit

75
  • Maxillary sinus cancers- 80 of all sinus cancers
  • Long history of sinusitis, nasal obstructions and
    bloody discharge
  • Squamous cell carcinomas
  • Invade the floor of the orbit, ethmoid sinuses,
    hard palate zygomatic arch
  • Displacement of the eye is common

76
  • Nasal cavity and paranasal sinus tumors are often
    associated with cranial nerve palsies- trigeminal
    branches
  • CT and MRI are the most useful studies
  • Submandibular node will be the first involved,
    although cervical node spread is uncommon

77
  • Treatment- Surgery is the treatment of choice
  • Primary radiation therapy has a chance of optic
    nerve damage from the high dose required for
    tumor control
  • Surgery and radiation therapy used in most cases
  • Lateral and anterior ports are used
  • When the orbit is involved, eye blocking will not
    be used
  • Care should be taken to miss the cord and
    contralateral lens

78
  • Angling the anterior beam a few degrees off the
    vertical spares brain tissue
  • Nasal cavity risk- Bolus material will be
    inserted to improve dose homogeneity
  • Angling the lateral port a few degrees off the
    horizontal plane spares the contralateral optic
    nerve and lens

79
Management of the Head and Neck Patient
80
  • Washington, Page 718, Table 30-3, dose-tissue
    response schedule
  • Page 719, Box 30-11, recommended skin care
    program
  • Care of the head and neck patient
  • Peridontal disease and caries
  • Nutrition
  • Mucositis/stomatitis

81
  • Xerostomia
  • Cataract formation
  • Lacrimal glands
  • Taste changes
  • Skin reactions
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