Head and Neck Case1

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    HEAD and NECK Case1

    Monica Kristine D. Reyes

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    Given

    1. 45 year old man

    2. 1x2cm firm, movable, non-tender mass: right side ofneck at level II.

    3. Patient took no notice: thought it was reactive

    lymphadenopathy (had cold).4. 4 weeks later: enlarged- 3x2cm

    5. No other pertinent neck findings.

    6. Posterior Rhinoscopy: reddish mass at the fossa of

    Rosenmuller on the right (confirmed on nasalendoscopy)

    7. Punch biopsy; undifferentiated CA

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    RecallLevel II: Skull base, Hyoid Bone, Submandibular Gland,

    Sternocleidomastoid Muscle

    The Level II lymph nodes extend from the skull base, at the lower levelof the bony margin of the jugular fossa, to the lower margin of thebody of the hyoid bone. Level II nodes are located anterior to a

    transverse line connecting the posterior edge of thesternocleidomastoid muscles and posterior to a transverse lineconnecting the posterior edge of the submandibular glands.

    Level IIA: These are Level II lymph nodes that are located anterior,medial or lateral to the internal jugular vein. These also define

    Level II lymph nodes that are posterior to the internal jugular veinbut directly abut the vein(22, 23).

    Level IIB: These nodes are posterior to the internal jugular vein andhave an identifiable fat plane between the lymph node and thevein(22, 23).

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    RecallRosenmuller fossa boundaries:

    1. Anterior: Eustachean tube and levator veli palati muscle.

    2. Posterior: Pharyngeal wall mucosa overlying thepharyngobasilar fascia and retro pharyngeal space,containing the retropharyngeal lymph nodes of Rouviere.

    3. Medial: Nasopharyngeal cavity.4. Superior: Foramen lacerum and floor of the carotid canal.

    5. Postero lateral (apex): Carotid canal opening and petrousapex posteriorly, foramen ovale and spinosum laterally.

    6. Lateral: Tensor palati muscle, mandibular nerve and theprestyloid compartment of the para pharyngeal space.

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    Recall

    Punch biopsy:

    The use of a biopsy punch

    in oral mucosal lesions is

    described and may be of

    some value. Punch biopsy

    may be difficult on freelymovable oral tissues and

    probably offers no

    advantage compared with

    scalpel biopsy. The

    technique may be

    appropriate in the hardpalate and other sites with

    better support and tissue

    that is bound down, and it

    is likely to produce a

    satisfactory specimen. The

    wound heals by secondaryintention, and discomfort

    may persist longer than

    anticipated by the

    clinician and the patient.

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    Diagnosis

    Nasopharyngeal Carcinoma metastasizing to the

    right cervical lymph nodes, level II

    WHO-3 category

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    Differentials

    I knowhindi tinatanongpero isama ko na rin

    Look up spondylosis, benign mixed tumor of thesalivary glands, mucoepidermoid carcinoma

    and cervical disc herniation

    But since, nagbiopsy na ngaduh? =)

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    What personal and social history information would

    contribute to the diagnosis? Sex. Men have about double the risk of developing cancer of the nasopharnyx as women do.

    Race. This type of cancer more commonly affects people in Asia and northern Africa. In theUnited States, Asian immigrants have a higher risk of this type of cancer than do American-born Asians, which may be related to differences in diet. The Inuits of Alaska also have anincreased risk of nasopharyngeal cancer. Additionally, blacks are significantly more likely todevelop nasopharyngeal cancer than are whites.

    Age. Most cases of nasopharyngeal cancer occur in people between the ages of 30 and 55.

    Salt-cured foods. Chemicals released in steam when cooking salt-cured foods, such as fish,preserved vegetables and Chinese herbs, may enter the nasal cavity, increasing the risk ofnasopharyngeal carcinoma. In China, nasopharyngeal carcinoma has been linked to highconsumption of salted fish, and as people in Southeast China are adopting a more Westerndiet, their rates of nasopharyngeal cancer have been declining.

    Preserved meats. Preserved meats contain high levels of nitrates, which may increase therisk of nasopharyngeal carcinoma. ; high incidence in those with low vegetable consumption

    (carotenoids are protective) Epstein-Barr virus. This common virus usually produces mild signs and symptoms, such as

    those of a cold. Sometimes it can cause infectious mononucleosis. Epstein-Barr virus is alsolinked to several rare cancers, including nasopharyngeal carcinoma. In fact, the Epstein-Barrvirus can be found in almost all nasopharyngeal cancer cells.

    Family history. Having a family member with nasopharyngeal carcinoma increases your riskof the disease, though researchers aren't sure if this association is due to genetic or

    environmental factors. Smoking and alcohol use (including smokeless tobacco)

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    Is a Neck mass common for this

    diagnosis?

    The most common physical finding is a neck

    mass, which is observed in 80% of patients.

    Painless firm lymph node enlargement is

    present.

    http://emedicine.medscape.com/article/988165

    -overview

    http://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overview
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    Diagnostic Procedures1. Laboratories:

    a. Routine blood work, chemistry profile, CBC, liver function tests (rarecases of hepatic metastasis)

    b. EBV titers, IgA, IgG antibodies to viral capsid antigen (titers correlatewith tumor burden)

    c. CSF exam: seeding of the tumor (if invasion to skull base is observed)

    2. Imaging:

    a. CT: tumor extension, erosion of skull base, cervical lymphadenopathy,bone imaging (distant metastases)

    b. MRI: extent of tumor (intracranial extension)

    c. PET: questionnable neck nodes

    3. Biopsy

    (WHO-3 is undifferentiated carcinoma, including lymphoepithelioma. Thisentity consists of malignant epithelial cells with lymphocytic

    infiltration)

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    Other Histopathology Three subtypes of NPC are recognized in the World Health Organisation

    (WHO) classification [20]:

    type 1: squamous cell carcinoma, typically found in the older adultpopulation

    type 2: non-keratinizing carcinoma

    type 3: undifferentiated carcinoma

    Most cases in childhood and adolescence are type 3, with a few type 2cases [21]. Type 2 and 3 are associated with elevated Epstein-Barr virustiters, but type 1 is not [22]. The Cologne modification of the WHOscheme by Krueger and Wustrow [23] includes the degree of lymphoidinfiltration. Types 2 and 3 may be accompanied by an inflammatoryinfiltrate of lymphocytes, plasma cells, and eosinophils, which areabundant, giving rise to the term lymphoepithelioma. Two histologicalpatterns may occur: Regaud type, with a well-defined collection ofepithelial cells surrounded by lymphocytes and connective tissue, andSchmincke type, in which the tumor cells are distributed diffusely andintermingle with the inflammatory cells. Both patterns may be present inthe same tumor.

    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1559589

    http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=322869&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=322869&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=322871&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=322871&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=340937&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=340937&version=Patient&language=Englishhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1559589http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1559589http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=340937&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=322871&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46683&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=322869&version=Patient&language=English
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    Treatment Options

    1. Surgery: Due to the anatomical position of NPC and its tendency topresent with cervical lymph node metastases, it is not amenable tosurgery for local control. Biopsy of the involved lymph node is the usualsurgical procedure. The nasopharyngeal primary tumor is rarelybiopsied.

    2. Chemotheraphy: NOTE- doxorubicin, methotrexate and

    cyclophosphamide would produce infertility in bo