38 y/o Male Chief complaint: Oral ulcer

Review of Systems (-) Past Medical History (-)

10 pack year smoking history (+) alcoholic beverage drinker

Oral cavity: 2x2cm ulcer, lower gingiva near the retromolar trigone

Neck: 4x4cm firm well-delineated, slightly movable mass at the left jugulo-digastric area

-3x3cm firm, well-delineated, movable mass at the lower third of the SCM

Thyroid gland: Negative for masses

38 y/o Male 10 pack year smoking history (+) alcoholic beverage drinker 2x2cm ulcer, lower gingiva near the retromolar

trigone 4x4cm firm well-delineated, slightly movable

mass at the (L) jugulo-digastric area 3x3cm firm, well-delineated, movable mass at

the lower third of the SCM thyroid gland: (-) mass

TB adenopathy Metastatic carcinoma from oral

cavity cancer Lymphoma Lymphadenitis from aphthous

ulcer

SCC is the most common type (>90%) Risk factors: alcohol and tobacco use, Symptoms: non healing wound, pain, “on

and off” bleeding , pain in swallowing, ear pain, a change in speech, uncoordinated swallowing, or a lump in the neck

sores in the mouth, whether they are related to trauma or to a variation of canker sores, should fully heal within three weeks

http://www.headandneckcancer.org/patienteducation/docs/oralcavity.php

80 % of unilateral neck mass are cervical metastasis from HNSCC

Oral cavity CA metastasize to the nodes in the ff levels:› Level 1 -submental,submandibular nodes› Level 2 –upper jugular chain nodes› Level 3 –middle jugular chain nodes

Schwartz’s Manual of Surgery 8th Ed.

Aphthous ulcer› Also referred to as canker sore, painful, open

sore in the mouth; white or yellow and surrounded by a bright red area

› they are benign› inner surface of the cheeks and lips, tongue,

soft palate, and the base of the gums› emotional stress, dietary deficiencies

(especially iron, folic acid, or vitamin B-12), menstrual periods, hormonal changes, food allergies, most commonly with viral infections

may also be linked to problems with the body's immune system, mouth injury due to dental work, aggressive tooth cleaning, or biting the tongue or cheek

SYMPTOMS: tingling or burning sensation, pain, less common symptoms are fever, malaise, swollen lymph nodes

complete healing in 1 to 3 weeks large ulcers (>1 cm) take 2 to 4

weeks to heal may recur monthly or several times a

year

http://www.nlm.nih.gov/medlineplus/ency/article/000998.htm

Ulcers in the gingiva, tongue, palate, and tonsillar area

Clinical features: Elevated,ulcerated area that may proliferate rapidly, giving the appearance of traumatic inflammation

underlying HIV infection

Harisson’s Principles of Internal Medicine 17th ed. Vol 1 p217

TB adenopathy Metastatic carcinoma from oral

cavity cancer Lymphoma Lymphadenitis from aphthous

ulcer

Metastatic Carcinoma from Oral Cavity CA

visual inspection of the oral and nasal cavities, neck, throat, and tongue using a small mirror and/or lights

also feel for lumps on the neck, lips, gums, and cheeks

complete head and neck examination with indirect nasopharyngeal and laryngopharyngeal mirror examination

use a thin, lighted tube called an endoscope to examine areas inside the body

type of endoscope to be used will depend on the area being examined

Laryngoscope - inserted through the mouth to view the larynx;

Esophagoscope - inserted through the mouth to examine the esophagus

Nasopharyngoscope - inserted through the nose so the doctor can see the nasal cavity and nasopharynx

TOLUIDINE BLUE- recommended for early detection as a guide for optimal biopsy. It clinically stains malignant lesions dark blue but does not stain normal mucosa. Dye is absorbed by the nuclei of malignant cells with increased DNA synthesis.

Follow with FNAB for cytology or excisional biopsy

If the diagnosis of carcinoma is made, endoscopic examination should proceed under general anesthesia with random biopsies of Waldeyer ring, the hypopharynx, nasopharynx, and other common sites of metastasis and any suspicious lesions

Subglottis, esophagus, and tracheobronchial tree are routinely evaluated to rule out synchronous primaries, which may have an incidence of 20%.

assess overall medical condition and possibility of spread to distant organs

Anemia may be detected with a CBC with platelet count

Liver function test determines hepatic spread

Nasopharyngolaryngoscopy (-)

Biopsy of ulcer: Well-differentiated Squamous Cell Carcinoma

Fine needle Biopsy of the neck mass: Chronic Lymphadenitis

makes a cut in the skin and removes the lymph node

If more than one lymph node is taken, the biopsy is called a lymph node dissection

Open biopsy and lymph node dissection takes a bigger sample than a needle biopsy

Done to check to see if a known cancer has spread to the lymph nodes (staging) and to plan cancer treatment

Chest radiograph PA and Lateral Panoramic view (Panorex) of the mandible

and/or dental X-rays. When necessary to adequately assess the status

of the patient's dentition RULE OUT (1) A synchronous pulmonary tumor,

(2) Acute or chronic pulmonary disease (3) Metastatic tumor.

Abnormal findings on chest x-ray or suspicious lesions need further imaging including a chest CT.

CT and MRI of the head, neck and superior mediastinum

› assess the presence and extent of nodal metastases, their relationship to the carotid and other adjacent structures, and to evaluate the superior mediastinum

› also useful to identify abnormalities in the base of tongue and nasopharynx that may suggest the location of the primary tumor, and to rule out parapharyngeal or paratracheal adenopathy

should also include the lung fields and liver for assessment of distant spread

Overall accuracy of nodal staging with CT (90-95%) appears superior to the accuracy obtained by clinical nodal staging (75-80%). Thus, more metastases are detected when CT is incorporated into the staging protocol of patients with primary head and neck squamous cell carcinoma

MRI of the head and neck with or without Gadolinium– Including the nasopharynx, skull base, and

neck, to attempt to locate the primary tumor within the nasopharynx and, if present, assess invasion of adjacent structures, such as the paraspinal muscles, infratemporal fossa, temporal bone, sphenoid sinus, bone marrow of the clivus, carotid artery, cranial nerves, and intracranial structures

– overall accuracy in staging LN same with CT – preferred method for staging SCC of the oral

cavity and oropharynx

• Panoramic x-ray (Panorex) of the mandible and/or dental X-rays. – When necessary to adequately assess the status

of the patient's dentition in anticipation of radiation therapy.

• PET scanning– additional diagnostic tool to improve the

accuracy of CT– In early radiologic studies, combination of CT

and PET has resulted in improved accuracy of staging, but this is not yet the standard of care

Standard for treatment of head and neck cancer

literature reports radiation therapy for patients with N0 or N1 necks and concludes that radiation or surgery can treat them equally well

• Nearly all patients with advanced disease require adjuvant radiotherapy, preoperatively or postoperatively

• Preoperative radiotherapy has the risk of increased complications of surgery

• Radiation dosage in excess of 6000 cGy is recommended with a boost to areas of high risk

• Indications:– include a bulky tumor with significant risk of

recurrence (T3 and T4)– histologically positive margins– perineural or perivascular invasion of tumor

INDICATIONS FOR NECK:

› elective treatment of the N0 neck not treated surgically where risk of micrometastasis is high

› gross residual tumor in the neck following neck dissection

› multiple positive lymph nodes

› extranodal extension of tumor

Head and neck examinations: (-)

Chest X-ray: (-)

Panoramic x-ray of mandible: lytic lesion of the body of the

mandible near the angle

• 3 x 2 cm ulcer of the lower gingiva with invasion into the mandible

• 5 x 4 cm well-encapsulated firm mass located at the submandibular triangle (level 1 to level 2 )

• Multiple pinkish-red, firm, grossly enlarged nodes (1-2 cm) along the jugular chain (levels 2 to 4)

• 4 x 3 cm well encapsulated firm mass at the subclavicular area

T N

M

Stage IVC

Wide excision of the ulcer with segmental mandibulectomy with modified radical neck dissection, left: the defect was reconstructed using titanium plates.

removes an entire segment of the mandible, disrupting continuity of the bone.  This is performed when tumor invades bone.

may be performed in the setting of a composite resection, › resection of a segment of mandible in

continuity with a cancer of the oral cavity or oropharynx or a primary cancer of the alveolar ridge.

http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-1-4160-2445-3..50037-6&isbn=978-1-4160-2445-3

Advantages› Adequate margins of resection› Excellent exposure› Ease of exposure

Disadvantages Cosmetic and functional consequences

Well differentiated squamous cell carcinoma with metastasis to 5/20 lymph nodes, the largest measures 2 cm with extracapsular invasion; margins clear; with bony invasion

Pre and post-op radiation› Improves local/regional control in HNSCC› within 6 weeks of surgery› 50 to 70 Gy over 5 to 7 weeks

Adverse reactions:› acute: mucositis, skin erythema› Late: fibrosis, xerostomia, altered state

No survival advantage compared to surgery and/or radiation› Cisplatin, carboplatin, 5-FU

Palliation of recurrent or unresectable disease, combined with radiation