Adult Neck MassesAdult Neck Masses
Ian Paquette MDIan Paquette MD
DHMC PGY 3-5 Teaching DHMC PGY 3-5 Teaching ConferenceConference
12/20/200612/20/2006
Head and Neck TumorsHead and Neck Tumors
Epithelial TumorsEpithelial Tumors Squamous Cell Carcinoma (>90%)Squamous Cell Carcinoma (>90%) Salivary GlandSalivary Gland AdenocarcinomaAdenocarcinoma ThyroidThyroid MelanomaMelanoma Neuroepithelial tumorsNeuroepithelial tumors Connective Tissue tumorsConnective Tissue tumors LymphomaLymphoma SarcomaSarcoma
Clinical PresentationClinical Presentation**In a smoker > 35 years old, these symptoms In a smoker > 35 years old, these symptoms suggest head and neck cancer until proven suggest head and neck cancer until proven otherwiseotherwise
OdynophagiaOdynophagia DysphagiaDysphagia Weight LossWeight Loss Loose DentitionLoose Dentition Oral FetorOral Fetor TrismusTrismus OtalgiaOtalgia Neck MassNeck Mass Serous Otitis MediaSerous Otitis Media
Nasal ObstructionNasal Obstruction EpistaxisEpistaxis Facial PainFacial Pain Cranial NeuropathiesCranial Neuropathies Secondary InfectionsSecondary Infections AspirationAspiration FistulizationFistulization HemorrhageHemorrhage Airway ObstructionAirway Obstruction
EvaluationEvaluation
Tobacco/AlcoholTobacco/Alcohol – Synergistic effect – Synergistic effect– 15 fold risk of squamous cell carcinoma of the head 15 fold risk of squamous cell carcinoma of the head
and neck compared to the general populationand neck compared to the general populationo Occupational FactorsOccupational Factors - - e.g., nickel workers, wood e.g., nickel workers, wood
workers implicated in paranasal sinus cancer workers implicated in paranasal sinus cancer o Epstein-Barr Virus (EBV)Epstein-Barr Virus (EBV) - - Possible etiological role in Possible etiological role in
nasopharyngeal carcinoma nasopharyngeal carcinoma o Radiation -Radiation - Increased risk of thyroid cancer, parotid Increased risk of thyroid cancer, parotid
neoplasms, malignant degeneration of papillomas and neoplasms, malignant degeneration of papillomas and possibly other upper aerodigestive tract neoplasmspossibly other upper aerodigestive tract neoplasms
EvaluationEvaluation
Physical ExamPhysical Exam– Head and Neck Examination - both Head and Neck Examination - both
inspection and palpation especially oral inspection and palpation especially oral cavity, base of the tongue, and palate cavity, base of the tongue, and palate
– General Physical Examination - distant General Physical Examination - distant metastases, coexisting medical problemsmetastases, coexisting medical problems
EvaluationEvaluationBiopsy - histologic confirmation of the diagnosis is Biopsy - histologic confirmation of the diagnosis is mandatory before pursuing definitive therapymandatory before pursuing definitive therapy
Superficial lesions - punch biopsy - ideal for Superficial lesions - punch biopsy - ideal for readily readily accessible lesions of the skin or mucosa accessible lesions of the skin or mucosa
Deeper lesionsDeeper lesions – Fine needle aspiration with cytology Fine needle aspiration with cytology – Large bore needle Large bore needle – Incisional biopsy - violates capsule and potentially Incisional biopsy - violates capsule and potentially
seeds tumor. seeds tumor. Useful when all diagnostic modalities Useful when all diagnostic modalities have failed to establish a diagnosis and excisional have failed to establish a diagnosis and excisional biopsy of the mass is not technically feasible.biopsy of the mass is not technically feasible.
– Excisional biopsy - removal of a suspected tumor Excisional biopsy - removal of a suspected tumor mass in its entirety. Rarely indicated in squamous mass in its entirety. Rarely indicated in squamous cell carcinomas of the upper aerodigestive tract.cell carcinomas of the upper aerodigestive tract.
Indications for FNAIndications for FNA
• Progressively Progressively enlarging nodesenlarging nodes
• A single asymmetric A single asymmetric nodenode
• A persistent nodal A persistent nodal mass without mass without antecedent active antecedent active signs of infectionsigns of infection
• Actively infectious Actively infectious condition that does condition that does not respond to not respond to conventional conventional antibioticsantibiotics
If no primary is found on examIf no primary is found on exam
Panendoscopy under anesthesiaPanendoscopy under anesthesia– NasopharyngoscopyNasopharyngoscopy– Direct laryngoscopyDirect laryngoscopy– BronchoscopyBronchoscopy– EsophagoscopyEsophagoscopy
– In most cases this identifies the primary In most cases this identifies the primary and will allow appropriate biopsies to be and will allow appropriate biopsies to be takentaken
If there is STILL no evidence of a primary?If there is STILL no evidence of a primary?
Random biopsiesRandom biopsies– NasopharynxNasopharynx– Piriform SinusPiriform Sinus– Base of tongueBase of tongue– Tonsillar fossaTonsillar fossa
StagingStaging
Panendoscopy under general anesthesiaPanendoscopy under general anesthesia– Direct LaryngoscopyDirect Laryngoscopy– EsophagoscopyEsophagoscopy– TracheobronchoscopyTracheobronchoscopy
Important due to a 5-15% incidence of Important due to a 5-15% incidence of synchronous tumorssynchronous tumors
TABLE 42.5 CORRELATION OF PRIMARY SITE AND STAGE OF HEAD AND NECK CANCER WITH SURVIVAL
RATES
Primary site
Survival rate (%)a
Stage I Stage II Stage III Stage IV
ORAL CAVITY
Tongue 70 50 40 20
Floor of mouth 70 50 25 10
Buccal mucosa 75 65 30 20
Alveolar ridge 80 65 35 15
PHARYNX
Nasopharynx 80 60 40 20
Oropharynx 80 60 30 20
Hypopharynx 60 50 30 10
LARYNX
Supraglottic 75 60 50 25
Glottic 95 80 50 30
Subglotticb
aThese numbers represent approximate averages; wide ranges have been reported for all sites and stages.bToo rare for meaningful survival data.
T1 > 2 cm, T1 > 2 cm, T2 2 – 4 cm T2 2 – 4 cm T3 > 4 cm T4 invasion T3 > 4 cm T4 invasion of antrum of antrum
N0 – no positive nodesN0 – no positive nodesN1 – single node < 3 cmN1 – single node < 3 cmN2a – single node 3 – 6 cmN2a – single node 3 – 6 cmN2b – multiple unilateral nodes < 6 N2b – multiple unilateral nodes < 6 cmcmN2c – multiple bilateral nodes < 6 N2c – multiple bilateral nodes < 6 cmcmN3 -- Nodes > 6 cm N3 -- Nodes > 6 cm
M (distant metastasis)M (distant metastasis)
StagesStagesI T1M0N0I T1M0N0II T2N0M0II T2N0M0III T3N0M0III T3N0M0 T1-3,N1M0T1-3,N1M0IV T1-3,N2-3M0IV T1-3,N2-3M0 T1-3N0-3M1T1-3N0-3M1
Squamous Cell Squamous Cell CarcinomaCarcinoma
TreatmentTreatment
The principles of therapy of head and The principles of therapy of head and neck cancer directed at cure of the neck cancer directed at cure of the disease should try to meet three disease should try to meet three objectives: objectives: – To eradicate the neoplasm completely To eradicate the neoplasm completely – To give the patient the best functional To give the patient the best functional
result by careful planning of the radiation result by careful planning of the radiation fields or appropriate reconstructive fields or appropriate reconstructive techniques for surgical defects techniques for surgical defects
– To leave the patient with as good a To leave the patient with as good a cosmetic result as possiblecosmetic result as possible
TreatmentTreatment
Multimodality treatments Multimodality treatments – Important to discuss at multi-Important to discuss at multi-
specialty tumor boardsspecialty tumor boards Alcohol/Tobacco cessationAlcohol/Tobacco cessation
– Up to 40% risk of recurrenceUp to 40% risk of recurrence– 10-40% risk of developing a 210-40% risk of developing a 2ndnd
primaryprimary
Stage 1 and 2Stage 1 and 2
Radiation or SurgeryRadiation or Surgery– Offer similar resultsOffer similar results– Choice depends on the exact site of Choice depends on the exact site of
the primary and the surgeon’s the primary and the surgeon’s preferencepreference
Stage 3Stage 3
Surgical TreatmentSurgical Treatment– Complete Resection plus Complete Resection plus
reconstructionreconstruction– Often need postoperative radiationOften need postoperative radiation– +/- Adjuvent Chemotherapy on an +/- Adjuvent Chemotherapy on an
individualized basisindividualized basis
Stage 4Stage 4
Chemotherapy Chemotherapy – Cisplatin, 5-FU, etcCisplatin, 5-FU, etc
Palliative SurgeryPalliative Surgery
Follow-UpFollow-Up
Monitor the patient's response to Monitor the patient's response to therapy therapy
To detect recurrence or second primary To detect recurrence or second primary – Every two months in the first year Every two months in the first year – Every three months the second and third Every three months the second and third
year year – At least every six months in the fourth and At least every six months in the fourth and
fifth years fifth years – Yearly thereafter Yearly thereafter
Salivary Gland TumorsSalivary Gland Tumors
Major Salivary GlandsMajor Salivary Glands– Parotid, submandibular, sublingualParotid, submandibular, sublingual
Minor Salivary glandsMinor Salivary glands– found in the submucosa of the found in the submucosa of the
nose, mouth, sinuses, and upper nose, mouth, sinuses, and upper aerodigestive tractaerodigestive tract
Tumors can occur in either major Tumors can occur in either major or minor glandsor minor glands
Salivary Gland TumorsSalivary Gland Tumors
Parotid Gland:Parotid Gland: 80% of salivary tumors 80% of salivary tumors– 80% of these are benign80% of these are benign
Submandibular Gland:Submandibular Gland: 10-15% of tumors 10-15% of tumors– 50% of these are benign50% of these are benign
Sublingual and minor glands:Sublingual and minor glands: 5-10% of 5-10% of tumorstumors– 40% are benign40% are benign
Benign TumorsBenign Tumors
Benign Mixed TumorBenign Mixed Tumor (Pleomorphic adenoma) (Pleomorphic adenoma) - The most common tumor of the - The most common tumor of the parotidparotid gland gland
Warthin's TumorWarthin's Tumor (papillary cystadenoma (papillary cystadenoma lymphomatosum) - Occurs most frequently in lymphomatosum) - Occurs most frequently in the "tail" of the parotid gland of white, the "tail" of the parotid gland of white, middle aged males. middle aged males. Appear "hot" on Tc99 Appear "hot" on Tc99 scan. Bilateral lesions commonly occurscan. Bilateral lesions commonly occur
Malignant TumorsMalignant Tumors
Often asymptomatic, but may show Often asymptomatic, but may show rapid tumor enlargement, pain, rapid tumor enlargement, pain, trismus, or facial nerve palsytrismus, or facial nerve palsy
FNA has 95% sensitivity in salivary FNA has 95% sensitivity in salivary gland neoplasms. Any patient with a gland neoplasms. Any patient with a salivary gland mass should undergo salivary gland mass should undergo FNAFNA– Incisional biopsy is Incisional biopsy is contraindicatedcontraindicated due to due to
tumor seedingtumor seeding
Malignant TumorsMalignant Tumors
Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma - Very lethal even when - Very lethal even when treated early. Although five-year survivals are quite treated early. Although five-year survivals are quite good, 20 year survival is very poor-15% or less good, 20 year survival is very poor-15% or less depending on site of origin. depending on site of origin. Most patients die of Most patients die of pulmonary metastasespulmonary metastases. This tumor also has a . This tumor also has a proclivity for perineural spread. proclivity for perineural spread.
Mucoepidermoid CarcinomaMucoepidermoid Carcinoma - Graded into high grade - Graded into high grade (very malignant and lethal) to low grade (very curable (very malignant and lethal) to low grade (very curable with surgery alone). The most common parotid tumor with surgery alone). The most common parotid tumor seen in seen in childhoodchildhood. .
Malignant TumorsMalignant Tumors
Acinic Cell CarcinomaAcinic Cell Carcinoma - Low grade - Low grade malignancy malignancy
Squamous Cell CarcinomaSquamous Cell Carcinoma - Very aggressive - Very aggressive tumor. tumor. Must rule out metastasis from a skin Must rule out metastasis from a skin lesion to parotid lymph nodeslesion to parotid lymph nodes. Primary . Primary parotid lesions tend to metastasize to parotid lesions tend to metastasize to
cervical lymph nodes.cervical lymph nodes.
Treatment of parotid Treatment of parotid tumorstumors
Superficial parotidectomy for Superficial parotidectomy for benign tumorsbenign tumors
Treatment of parotid Treatment of parotid tumorstumors
Malignant tumors often warrant Malignant tumors often warrant total parotidectomytotal parotidectomy
Facial nerve is sacraficed only for Facial nerve is sacraficed only for direct invasion or pre-existing direct invasion or pre-existing facial nerve paralysisfacial nerve paralysis
Squamous cell or high grade Squamous cell or high grade mucoepidermoid – may require a mucoepidermoid – may require a neck dissectionneck dissection
Treatment of parotid Treatment of parotid tumorstumors
RadiationRadiation– High grade tumorsHigh grade tumors– Close MarginsClose Margins– Recurrent diseaseRecurrent disease– Positive nodesPositive nodes– Unresectable diseaseUnresectable disease
No effective chemotherapyNo effective chemotherapy
Submandibular and Sublingual Submandibular and Sublingual glandsglands
o Complete excisions of the gland and tumor. Complete excisions of the gland and tumor. o If a malignancy is discovered, then a neck If a malignancy is discovered, then a neck
dissection and perhaps excision of the floor dissection and perhaps excision of the floor of mouth may be indicated depending on the of mouth may be indicated depending on the
tumor type.tumor type.
Minor Salivary GlandsMinor Salivary Glands
The operation depends on the location of the The operation depends on the location of the involved gland, involved gland, but complete excision with a but complete excision with a margin of normal tissue is essentialmargin of normal tissue is essential. .
In the case of In the case of adenoidcystic carcinomasadenoidcystic carcinomas, , surrounding nerves must be sampled for surrounding nerves must be sampled for
possible invasion and excised if involved.possible invasion and excised if involved.
THE ENDTHE END
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