Pictorial Lesson on Pictorial Lesson on Head and Neck CancerHead and Neck Cancer

H LordH Lord

Intra-Oral TumoursIntra-Oral Tumours

Intraoral CancerIntraoral Cancer

The majority of The majority of intraoral tumours intraoral tumours are concentrated in are concentrated in the relatively small the relatively small 'drainage' areas 'drainage' areas (highlighted in (highlighted in blue) where saliva blue) where saliva pools pools

LeukoplakiaLeukoplakia Also known as Also known as

smoker's keratosis, smoker's keratosis, this premalignant this premalignant tumour is marked by tumour is marked by extensive, irregular, extensive, irregular, white thickening or white thickening or plaques. plaques.

The woman shown The woman shown here habitually here habitually allowed cigarettes to allowed cigarettes to burn down to the end burn down to the end against her lip. A against her lip. A carcinoma carcinoma subsequently subsequently developed in this developed in this area area

Tumour Staging for lip and oral Tumour Staging for lip and oral cavitycavity

Nodal Staging for Lip and oral Nodal Staging for Lip and oral cavitycavity

Squamous cell carcinoma of Squamous cell carcinoma of tonguetongue

Located on the Located on the lateral border of lateral border of the tongue, as is the tongue, as is common with common with these tumors, these tumors, this nodular this nodular lesion was lesion was painless despite painless despite its being a well-its being a well-established established invasive tumour.invasive tumour.

Squamous cell carcinoma of Squamous cell carcinoma of retromolar region and soft palate.retromolar region and soft palate.

The lesion on The lesion on the alveolar the alveolar ridge shows ridge shows the typical the typical features of a features of a malignant malignant ulcer, but that ulcer, but that of the soft of the soft palate appears palate appears only as a only as a white patch.white patch.

Squamous cell carcinoma of floor Squamous cell carcinoma of floor of mouthof mouth

Panoramic Panoramic tomogram tomogram shows a shows a localized localized area of area of bone bone destruction destruction (arrow-(arrow-heads) in heads) in the body of the body of the the mandible mandible

Bone scanBone scan The photodeficient The photodeficient

area (arrowheads) area (arrowheads) corresponds to the corresponds to the area of bone area of bone destruction seen destruction seen on the tomogram.on the tomogram.

The area of The area of increased uptake, increased uptake, indicating the indicating the actual extent of actual extent of bone invasion, is bone invasion, is much greater, much greater, encompassing encompassing most of the most of the mandible. mandible.

Squamous cell carcinomaSquamous cell carcinoma

CT scan of CT scan of squamous squamous cell cell carcinoma carcinoma involving the involving the mandible mandible (arrows). (arrows).

Squamous cell carcinomaSquamous cell carcinoma These well-These well-

differentiated tumours differentiated tumours demonstrate the demonstrate the variable stromal variable stromal response that may be response that may be encountered, ranging encountered, ranging from (a) a heavy, from (a) a heavy, chronic inflammatory chronic inflammatory infiltrate surrounding infiltrate surrounding the invasive tumour, orthe invasive tumour, or

(b) an inflammation-(b) an inflammation-free stroma marked by free stroma marked by fibroblastic fibroblastic proliferation. Note the proliferation. Note the presence of numerous presence of numerous keratin pearls.keratin pearls.

Squamous cell carcinomaSquamous cell carcinoma Poorly Poorly

differentiated differentiated tumours are tumours are marked by sheets marked by sheets of immature cells of immature cells and no evidence of and no evidence of keratinization. keratinization.

Neoplastic cells Neoplastic cells show extreme show extreme degrees of degrees of pleomorphism, pleomorphism, often with bizarre often with bizarre mitoses mitoses

Pharyngeal TumoursPharyngeal Tumours

Staging of Pharyngeal CancerStaging of Pharyngeal Cancer

Nodal Staging and Mets for Nodal Staging and Mets for nasopharyngeal Canasopharyngeal Ca

Squamous cell carcinoma of Squamous cell carcinoma of oropharynx.oropharynx.

A 53-year-old woman presented A 53-year-old woman presented with odynophagia and nasal with odynophagia and nasal regurgitation of food. regurgitation of food.

Examination reveals a large, Examination reveals a large, exophytic, ulcerative lesion of the exophytic, ulcerative lesion of the left tonsil that diffusely involves left tonsil that diffusely involves the soft palate and uvula. Palatal the soft palate and uvula. Palatal insufficiency resulted from a insufficiency resulted from a fistula in the right soft palate fistula in the right soft palate extending into the nasopharynx.extending into the nasopharynx.

After treatment with combination After treatment with combination chemotherapy, the lesion chemotherapy, the lesion completely regressed, replaced completely regressed, replaced by fibrous tissue, and the fistula by fibrous tissue, and the fistula closed. Treatment continued with closed. Treatment continued with definitive radiotherapy. The definitive radiotherapy. The patient remains free of disease in patient remains free of disease in long-term followup.long-term followup.

Squamous cell carcinoma of Squamous cell carcinoma of nasopharynxnasopharynx

A 64-yo woman A 64-yo woman presented with a presented with a persistent serous persistent serous effusion of the right effusion of the right middle ear. middle ear.

Axial CT scan: soft Axial CT scan: soft tissue mass in the tissue mass in the right lateral aspect of right lateral aspect of the nasopharynx close the nasopharynx close to fossa of to fossa of Rosenmuller, Rosenmuller, infiltrating deeply and infiltrating deeply and involving the involving the Eustachian tube. Eustachian tube.

Fascial planes Fascial planes destroyed by the destroyed by the advancing neoplasm advancing neoplasm (compare with normal (compare with normal left side).left side).

Squamous cell carcinoma of Squamous cell carcinoma of nasopharynxnasopharynx

Coronal CT section Coronal CT section shows a tumour shows a tumour extending into the extending into the middle cranial fossa middle cranial fossa (medium arrow) and (medium arrow) and inferiorly through the inferiorly through the inferior orbital fissure inferior orbital fissure (short, thick arrow), (short, thick arrow), which is markedly which is markedly widened (open arrow). widened (open arrow).

Tumour is also present Tumour is also present in the superior aspect of in the superior aspect of the nasal cavity (thin the nasal cavity (thin arrow). There is a soft arrow). There is a soft tissue thickening within tissue thickening within the sphenoid sinus. the sphenoid sinus.

Squamous carcinoma of Squamous carcinoma of nasopharynxnasopharynx

A 35-year-old A 35-year-old woman woman complained of complained of nasal stuffiness. nasal stuffiness.

Sagittal T1-Sagittal T1-weighted MRI weighted MRI image shows a image shows a large soft tissue large soft tissue mass (arrows) mass (arrows) involving the involving the sphenoid sinus, sphenoid sinus, ethmoid sinus and ethmoid sinus and clivus clivus

Boney destructionBoney destruction CT scan shows CT scan shows

the extent of the extent of bony involvement bony involvement of clivus; petrous of clivus; petrous temporal bone; temporal bone; sphenoid bone; sphenoid bone; and ethmoidand ethmoid

Squamous cell carcinoma of Squamous cell carcinoma of oropharynxoropharynx

A 63-year-old woman A 63-year-old woman presented with difficulty presented with difficulty in swallowing and otalgia.in swallowing and otalgia.

Examination reveals an Examination reveals an

extensive lesion of the extensive lesion of the right tonsil that involves right tonsil that involves the lateral pharyngeal the lateral pharyngeal wall, as well as the soft wall, as well as the soft palate and uvula.palate and uvula.

After biopsy, which After biopsy, which confirmed the diagnosis, confirmed the diagnosis, the lesion was outlined the lesion was outlined (tattooed) with India ink (tattooed) with India ink and treated with and treated with combination combination chemotherapy and chemotherapy and radiotherapy. radiotherapy.

Response to treatmentResponse to treatment This photograph, This photograph,

taken after taken after chemotherapy but chemotherapy but before radiotherapy, before radiotherapy, shows complete shows complete clinical regression of clinical regression of

the tumourthe tumour

Laryngeal TumoursLaryngeal Tumours

Staging of Laryngeal TumoursStaging of Laryngeal Tumours

Squamous cell carcinoma of larynxSquamous cell carcinoma of larynx Axial CT scan at the level of the Axial CT scan at the level of the

posterior lamina of the cricoid posterior lamina of the cricoid cartilage (arrow 1) shows cartilage (arrow 1) shows subglottic extension of an subglottic extension of an intralaryngeal tumour mass intralaryngeal tumour mass (arrow 2). The thyroid cartilage is (arrow 2). The thyroid cartilage is indicated (arrow 3) indicated (arrow 3)

Section through the glottis (about Section through the glottis (about 1 cm cephalad to the previous 1 cm cephalad to the previous scan) shows that necrotic tumour scan) shows that necrotic tumour extends anteriorly into the soft extends anteriorly into the soft tissue of the neck. The central tissue of the neck. The central portion of the thyroid cartilage portion of the thyroid cartilage has been destroyed. has been destroyed.

The tumour encroaches on the The tumour encroaches on the airway and has obliterated the airway and has obliterated the anterior commissure. This is anterior commissure. This is classified as a T4 lesion.classified as a T4 lesion.

Squamous cell carcinoma of larynxSquamous cell carcinoma of larynx A 68-yo man, long history A 68-yo man, long history

of alcohol and tobacco of alcohol and tobacco use, progressive dysphagia use, progressive dysphagia and hoarseness. and hoarseness. Laryngoscopy reveals a Laryngoscopy reveals a large exophytic lesion of large exophytic lesion of the supraglottic larynx that the supraglottic larynx that involves the aryepiglottic involves the aryepiglottic fold, the false vocal cord fold, the false vocal cord and the infrahyoid and the infrahyoid epiglottis. epiglottis.

The true glottis is obscured The true glottis is obscured but immobile. With the but immobile. With the discovery of several small discovery of several small ipsilateral cervical lymph ipsilateral cervical lymph nodes, the patient was felt nodes, the patient was felt to have stage IV (T3N2b) to have stage IV (T3N2b) disease. disease.

Radiotherapy was Radiotherapy was administered when the administered when the patient refused surgical patient refused surgical resection. 28 months after resection. 28 months after radiotherapy, there is no radiotherapy, there is no evidence of tumour. evidence of tumour.

Sinus TumoursSinus Tumours

Staging of Tumours of the SinusesStaging of Tumours of the Sinuses

Squamous cell carcinoma of Squamous cell carcinoma of maxillary sinusmaxillary sinus

Coronal CT scan shows Coronal CT scan shows intraorbital extension from intraorbital extension from a large carcinoma arising a large carcinoma arising in the right maxillary in the right maxillary sinus. The tumour extends sinus. The tumour extends medially into the nasal medially into the nasal cavity, superiorly into the cavity, superiorly into the ethmoid labyrinth, and ethmoid labyrinth, and anterolaterally into the anterolaterally into the oral cavity. oral cavity.

There is obvious extension There is obvious extension of tumour into the orbit of tumour into the orbit with destruction of the with destruction of the normal bony landmarks; normal bony landmarks; the floor of the orbit (roof the floor of the orbit (roof of the maxillary sinus) is of the maxillary sinus) is fragmented (compare fragmented (compare with left orbit). with left orbit).

In this plane, the bony In this plane, the bony floor of the anterior floor of the anterior cranial fossa appears cranial fossa appears intact. A fluid level is intact. A fluid level is present in the left present in the left maxillary sinus.maxillary sinus.

Carcinoma of ethmoid sinusCarcinoma of ethmoid sinus

CT scans show CT scans show a tumor a tumor expanding the expanding the ethmoid sinus, ethmoid sinus, destroying the destroying the medial orbital medial orbital wall and wall and invading invading posteriorly into posteriorly into the middle the middle cranial fossa.cranial fossa.

EsthesioneuroblastomaEsthesioneuroblastoma A 16-year-old boy A 16-year-old boy

presented with nasal presented with nasal obstruction of recent obstruction of recent onset. (a) Axial CT onset. (a) Axial CT scan shows a large scan shows a large expansile mass expansile mass (arrows) in the right (arrows) in the right nasal cavity. nasal cavity.

The medial wall of the The medial wall of the orbit is bowed orbit is bowed outward, displacing outward, displacing the globe laterally. the globe laterally. The anteromedial The anteromedial wall of the maxillary wall of the maxillary sinus is displaced but sinus is displaced but appears intact. appears intact.

Tumours of the Tumours of the Salivary GlandsSalivary Glands

T categories and stage grouping for T categories and stage grouping for cancer of the major salivary glands cancer of the major salivary glands

Pleomorphic adenoma of parotid Pleomorphic adenoma of parotid gland.gland.

Clinically, as Clinically, as is common is common with these with these tumours, tumours, there is a there is a painless painless swelling; in swelling; in this instance, this instance, the tumour the tumour involves the involves the lower pole of lower pole of the gland.the gland.

LymphomaLymphoma

Diffuse large cell lymphoma of Diffuse large cell lymphoma of oropharynxoropharynx

Additional evaluation Additional evaluation of this 33-year-old of this 33-year-old man who presented man who presented with right tonsillar with right tonsillar enlargement enlargement revealed only this revealed only this jugulodigastric mass; jugulodigastric mass; biopsy yielded the biopsy yielded the histologic diagnosis. histologic diagnosis. For clinical stage II For clinical stage II disease, he received disease, he received six cycles of six cycles of combination combination chemotherapy, which chemotherapy, which resulted in a resulted in a complete response. complete response. He remains disease He remains disease free 8 years after free 8 years after treatment.treatment.

Diffuse large cell lymphomaDiffuse large cell lymphoma Clinical stage I disease. Clinical stage I disease.

This axial MR scan reveals This axial MR scan reveals a soft tissue mass within a soft tissue mass within the neck consistent with the neck consistent with malignant regional malignant regional adenopathy. The adenopathy. The homogeneous texture of homogeneous texture of the lesion favours a the lesion favours a diagnosis of lymphoma diagnosis of lymphoma which was confirmed after which was confirmed after an initial, unremarkable, an initial, unremarkable, evaluation of the head and evaluation of the head and neck mucosal surfaces neck mucosal surfaces under aneasthesia by a under aneasthesia by a head and neck surgeon head and neck surgeon and subsequent excisional and subsequent excisional biopsy of the neck lesion.biopsy of the neck lesion.

Diffuse large cell lymphoma of Diffuse large cell lymphoma of oropharynxoropharynx

A 24-year-old man, a A 24-year-old man, a non-smoker, presented non-smoker, presented with a 3-week history with a 3-week history of odynophagia and of odynophagia and fatigue refractory to a fatigue refractory to a trial of antibiotics. trial of antibiotics.

A massive necrotic A massive necrotic lesion of the right lesion of the right tonsil is apparent. tonsil is apparent. Intraoral biopsy Intraoral biopsy yielded the histologic yielded the histologic diagnosis diagnosis