1overview of head & neck tumours

8/8/2019 1Overview of Head & Neck Tumours

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ASSOC PROF DR BAHARUDIN ABDULLAH

Dept of Otorhinolaryngology-Head & Neck Surgery

School Of Medical Sciences

Universiti Sains Malaysia

ENT Head and Neck Radiology Seminar16-17 July 2010Hospital Ampang


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Definition:Tumours (neoplasm) is a mass of tissue formedas a result of abnormal, excessive andinappropriate proliferation of cells, the growthof which continues indefinitely and regardlessof the mechanisms which control normalcellular proliferation.


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Classification:Benign-a single mass, localized, symptomless, can

be excised completelyMalignant-invade surrounding tissues,spread by

lymphatics and BV to other parts of body


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50% present beforeage 20

Midline (75%) or nearmidline (25%)Elevates onswallowing/protrusio

n of tongueSurgery


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Cystic mass anterior toSCM, below mandibleMay get infected

Persistence of 2nd

branchial cleftMay have small sinustract into tonsillar fossaContains cholesterolcrystals

Video


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Cystic swelling floor of mouth( ranula-littlefrog)Mucous extravasation from sublingual salivarygland.May extend through FOM muscles into neck-Plunging Ranula


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1) Marking2) Skin incision3)Mobilization1 ,Mobilization24) Preservation of Lingual Nerve5)Ligation of Submandibular Duct6)Specimen
http://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/marking.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/incision.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/mobilization1.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/mobilization2.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/LingualNerve.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/Duct.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/Specimen.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/Specimen.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/Duct.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/LingualNerve.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/mobilization2.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/mobilization1.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/incision.mpeghttp://d/CLINICAL_VIDEO/SubmandibularMass/SitiFarah_B370230_Pleomorphic/Operation_24Jul08/Video/marking.mpeg


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Dr Baharudin AbdullahDr VMK BhavarajuDr Win Mar@ SalmaDr Mutum S Singh

1 Dept of ORL-HNS, School of Medical Sciences, Univ. Sains Malaysia.2 Dept of Nuclear Medicine, School of Medical Sciences, Univ. Sains Malaysia.

3 Dept of Radiology, School of Medical Sciences, Univ. Sains Malaysia.4 Dept of Pathology, School of Medical Sciences, Univ. Sains Malaysia.

International ORL Audiology Meeting 2007Rosario, Argentina


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A 19yr Female was referred for left sidedneck swelling just below the ear of >4 yearsdurationHistory of:

Recent increase in the swelling present

Mild pain in the swelling occasionally with noh/o radiation of painLOA & LOW present

Case Presentation


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No history of :Nasal discharge or blockageHearing defects or ear dischargeAny difficulty or pain while swallowingFacial asymmetry notedVoice changes

Contact with Tuberculosis patientNo other swelling over the body or any discolorationnoted


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Oropharynx:Bulging of the left lateral pharyngealwallNo evidence of inflammation

Nasopharynx:No obvious mass seen at fossa ofRosenmuller or at the roof


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Loose stroma, psammoma body


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Stained with vimentin and EMA-differentiate from glioma, schwannoma


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Patient underwent a tumor debulking via atransparotid approach and received post operativeradiation to the residual tumorA dose of 45 Gy/25#/5 weeks delivered by a 6 MvLinear AcceleratorPost operative Irradiation is given to reduce thelocal recurrenceTo prolong the disease free survivalA dose to be delivered depend on the normal tissuetoleranceIn the present case cervical spinal cord is thelimiting factor for the radical dose of radiation to bedelivered


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Type 1 direct extension from intracranial tumorthrough foraminaType 2 extra cranial growth from arachnoid withinthe cranial nerve sheath

Type 3- extra cranial growth from ectopic or embryoniccell rest arachnoid without connection to skull base orcranial nerveType 4 distant metastases from intracranialmeningioma


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1. Nasopharyngeal Carcinoma2. Laryngeal Carcinoma3. Oral cavity Cancers4. Thyroid Cancer5. Salivary Gland Cancer6. Skin Cancers of Head and Neck

7. etc. such as Ca Ear, Ca Nose and ParanasalSinuses


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6th most common cancer worldwideHNSCC ~ 5% all cancersSCC most common upper aerodigestive tract

malignancySmoking and alcoholManagement presents considerable functionaland aesthetic problemsMultidisciplinary approach imperative


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Complete HistoryPhysical examination

Endoscopic assessment of upper aerodigestivetract.Imaging studies US/CT scanBiopsyTreatment


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Rim enhancementCentral necrosisNodal size > 1cmObliteration of tissue planes


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FNAVery accurateOpen BiopsyShould be avoidedCan complicate future therapy


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SafeRapidInexpensivePresurgicalplanning, patient counselling.Avoids open biopsyNo evidence of tumour seeding in HAN


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SafeRapidInexpensive

Presurgicalplanning,patient counselling.Avoids open biopsyNo evidence of

tumour seeding inHAN


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Primary tumour+ cervical nodesSurgery/DXRT/ChemotherapySometimes palliationCervical neck disease reduces survival by 50%


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Cancers of the oral cavity are treated by primarysurgical resection. Adjuvant radiotherapy orconcurrent chemoradiation is indicated for high-riskgroup.

Tumors of the pharynx (oropharynx or hypopharynx)are treated primarily with combined chemoradiation.Laryngeal cancers are also treated with chemoradiationif the larynx is functional. However, if the tumor hasdestroyed the laryngeal skeleton, surgery may berequired to restore an adequate airway and maintainswallowing.


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Symptoms & Signs - Persistent SOM- Neck Mass (Laterally at level 2)- Nasal S&S - Nasal obstruction- Nose Bleed or Bloody discharge- etc.- Cranial Nerve 5, 6, 9, 10, 11 and 3 & 4

- Miscellaneous - Headache- Feeling lump in throat


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Treatment - Radiation is a major role- External- Brachy therapy

- Stereotactic Radiation or Gamma knife- Chemotherapy is an adjunctive modality- Surgery - Eradicate residual lymphnodes orprimary resectable disease- PDT- etc


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The WHO classification based on the degree of differentiation.Type I: keratinizing squamous cell carcinoma (SCC), similar toother head and neck cancer.Type II: nonkeratinizing carcinoma (IIa)Type III: undifferentiated carcinoma, has a typical morphologywith a prominent lymphoplasmacytic infiltrate, and is alsoreferred as lymphoepithelioma. (IIb)In endemic areas, WHO Type III accounts for more than 97%,while keratinizing SCC is more common in the Western countries(~75%).

Latent EBV infection is uniquely present in almost all NPC fromendemic regions, but absent in WHO Type I NPC from non-endemic regions.


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Baharudin AbdullahShahid Hassan

Department of ORL-HNSSchool of Medical SciencesUniversiti Sains Malaysia


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Introduction

Benign, malignant skull base tumour notuncommonConventional approach for early tumors

For extensive/intracranial/recurrent tumornasopharynx difficult to approachadequate exposure for surg. control of tumour


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Nasopharyngeal Pathology

Total no.of case - 09

Extensive JNA - 02

Recurrent JNA - 03

Chordoma - 01

Recurrent NPC - 03


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Hospitals - procedure carried outHospital Universiti Sains Malaysia 07 Cases

Tg. Ampuan Afzan Hosp. Kuantan 01 Case

General Hospital K. Bharu, Kelantan 01 Case


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Approaches to central Skull Base

Superior TranscranialInferior TranspalatalLateral InfratemporalAnterior TransantralAnterolateral Maxillary Swing


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Exposure Achieved in C.S.Base

Other S.B.Approach Maxillary Swing Approach

Nasopharyngeal region In addition to C.S. BaseEustachian tube Pterygopalatine fossaParanasopharyngeal area Infratemporal fossa

Floor of the orbit if eroded


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JNA - Introduction

Benign but recurrent diseaseIncidence 1 in 5000 - 1 in 60 0000.5% of all Head and Neck tumorOrigin - sphenopalatine foramenTreatment - surgical resection


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JNA Management and Outcome

Type I & II Small one window approachType III External cervical approachType IV Combined N.surg. approachRecurrent Resection by E.C. approach

Rx.for Intracranial extension


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JNA Problem of Recurrence

Difficult revision surgery

Inaccessible extensionInadequate exposureAdhesion and fibrosis

Infratemporal fossa approachDifficult to performInherited complication


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JNA-Indication and Feasibility

Extensive or recurrent growthTumor eroding skull baseIntracranial extradural extension

Opportunity of I.M.A ligation


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Result - JNA

Fast and complete healingAcceptable complicationsAdequate tumour exposure

Feasible and complete excisionNo recurrence in all 05 cases


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NPC - Introduction

Malignant and recurrent diseaseTreatment of choice radiotherapy8% of all malignancies in H & N clinic

18% in certain racial areas like HK


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NPC- Management and Outcome

T1 N0 Lesion - claimed 50% cureT2 N1 Lesion - 38% 5 yrs survivalT3 N2 lesion - 15% 5yrs survival


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Problem of recurrent disease

Usually associated with neck gland metastasis

Radiotherapy/ chemotherapy/ BrachytherapyConcomitant therapy effective but >morbidity

Greater dosage needed will increase morbidity


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NPC-Indication and Prerequisite

Recurrent NPCNot eroding S.B.No neck metastasis

Tumor not > 2 cm in size


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Result - NPC

Avoid dose-effective radiotherapy( Expected worst side effect)Reported better prognosis

Complete excisionAcceptable complication


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Chordoma - Introduction

Rare malignant lesion with incidence


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Problem of Management

Extensive tumor on presentationSurgical resection rarely possibleRadiotherapy, dose-effect relationshipHigh dose, safety , meticulous technique


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Problem of Recurrence

Recurrent disease poorer prognosisLimited choice of available treatmentPalliation radiotherapy with morbiditySurgical resection a difficult procedure


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Chordoma-Indication andPrerequisite

History of late presentationDifficult trans -cranial approach

Erosion of clivus and S. tursicaExtradural brainstem encroachment


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Result - Chordoma

Tumour excision by double swing procedureCombined Ext cervical, Neurosurgical approach

Surgical resection a better prognosis

Neurosurgical excision under expert hand


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Maxillary SwingProcedure


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Instruments for the Maxillary Swing Procedure


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Facial incision Palatal incision


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Anterolateral wallMaxilla swung laterally


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Repair of anterior wall Repair of zygoma


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ComplicationsEpiphora 01 case

Trismus 01 case

Palatal fistula 01 case


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Complications of Maxillary swing Procedure


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Conclusion

Offers adequate exposure of NPExcision of extensive and recurrent tumor

Combining with other approaches possibleAlternate to trans-cranial approach in chordoma

Re-radiation effects can be avoided in NPCBetter prognosis achieved in selected cases


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Ca oropharynx Ca hypopharynx


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Divided into- Glottic- Supraglottic

- Sub glottic- Transglottic


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Management -Surgery isa major role (with orwithout laser)

RadiationCombination of Surgeryand RadiationRadiation +Chemotherapy in Organpreservation


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Ca Tongue 45%Ca Floor Of Mouth 25%Ca Alveolus(Upper& Lower) 20%

Ca Buccal Mucosa 7.5%Ca Palate 2.5%


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1. Well differentiated-Papillary-Follicular

-Mixed (Pap+Foll)2. Poorly differentiated-Hurthle Cell-Medullary-Anaplastic-Malignant Lymphoma


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I.Epithelial tumour:

A. Benign- follicular adenoma (90%), Hurtle cell adenoma (10%)B. Malignant- Papillary (80%), follicular (10%), Hurtle cell (3%),

Medullary(5%);Anaplastic(1%), squamous cell car.

II. Nonepithelial

III.Malignant lymphoma

IV.Miscellaneous e.g teratomas

V. Secondary tumours

VI.Unclassified tumours

VII. Tumour-like lesions e.g thyroiditis, thyroid cysts, hyperplasticgoitres, amyloid goitres.


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Commonest as a solitary thyroid nodule (10%incidence malignant; increase after 50-60 yearsof age ;males)

-cervical lymphadenopathy(20%)-rapidly enlarging goitre-pain in the neck ,stridor ,dysphagia ,

hoarseness, evidence of metastasisMajority of malignancy-euthyroidFamily history and other tumours in MEN


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Past history of ionising radiationFamily history of thyroid cancerHistory of previous thyroid cancer

Rapidly growing or painfulMale ptPresence of neck or distant metastasisHard, fixed nodule with vocal cord paralysis orrecurrence cystic noduleUnder age of 14 or over 65 years of age


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MultidisciplinarySelection of combination modalities depend onextent of disease, the prognostic factors andrisk group analysis

Treatment modalities1.Surgery2.Radioactive iodine3.External beam radiotherapy4.Thyroxine therapy5.Chemotherapy


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-total lobectomy -complete removal of one thyroid lobe and theisthmus-near-total thyroidectomy :total lobectomy and isthmusectomy with

removal of more than 90% contralateral lobe-total thyroidectomy : removal of both thyroid lobes and isthmus

Minimum operation for suspected or confirmed thyroid cancer istotal lobectomy on side of lesion; often, near total thyroidectomyperformed initially.

-Collar incision at least 2 cm above suprasternal notch-may needextension to facilitate neck dissection or mediastinal exploration

-Preservation of recurrent laryngeal nerves ,parathyroids, externallaryngeal nerves important

-operation include level VI dissection


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Major arguments proposed for total thyroidectomy:1.Presence of microscopic disease in opposite lobe(multicentricity varies between 30-70%)2.Local recurrence in opposite lobe 5-15%3.Need for radioactive iodine follow up and thyroglobulinas a tumour marker which can be used only after total

thyroidectomy4. Hypothetical small risk of anaplastic transformation of

residual thyroid tissue5. High incidence of complication in re-operative thyroidsurgery


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Proponents for less than total thyroidectomy :1)Complication of routine total thyroidectomy

more disastrous2)Microscopic multicentric papillary cancer has

little prognostic implication and localrecurrence in contralateral lobe less than 5%


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Malignant MixedTumorMucoepidermoid Carcinoma-High Grade-Intermediate Grade

-Low GradeAdenoid Cystic CarcinomaAdenocarcinomaOncocytic Cell Ca

Squamous Cell Ca.Undifferentiated Cell Ca

2007 ICD-9-CM Volume 1 Diagnosis CodesDiseases Of Oral Cavity, Salivary Glands, And Jaws


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y, y ,ICD-9-CM Diagnosis 527Diseases of the salivary glands

A non-neoplastic or neoplastic (benign or malignant) disorder involving the salivary gland.

ICD-9-CM Diagnosis 527.0 Atrophy of salivary gland

ICD-9-CM Diagnosis 527.1Hypertrophy of salivary gland

ICD-9-CM Diagnosis 527.2SialoadenitisInflammation of the parotid gland.

ICD-9-CM Diagnosis 527.3 Abscess of salivary gland

ICD-9-CM Diagnosis 527.4Fistula of salivary gland

A fistula between a salivary duct or gland and the cutaneous surface of the oral cavity.

ICD-9-CM Diagnosis 527.5SialolithiasisCalculi occurring in a salivary gland. Most salivary gland calculi occur in the submandibular gland, but can also occur in the parotidgland and in the sublingual and minor salivary glands. Presence of small calculi in the terminal salivary ducts (salivary sand), orstones (larger calculi) found in the larger ducts.

ICD-9-CM Diagnosis 527.6Mucocele of salivary gland

A form of retention cyst of the floor of the mouth, usually due to obstruction of the ducts of the submaxillary or sublingual glands,presenting a slowly enlarging painless deep burrowing mucocele of one side of the mouth.

ICD-9-CM Diagnosis 527.7Disturbance of salivary secretion

An oral condition in which salivary flow is reduced. Decreased salivary flow.Dry mouth. It occurs when the body is not able to make enough sa liva.Increased salivary flow.

ICD-9-CM Diagnosis 527.8Other specified diseases of the salivary glands

ICD-9-CM Diagnosis 527.9Unspecified disease of the salivary glands

A non-neoplastic or neoplastic (benign or malignant) disorder involving the salivary gland.


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WHO HISTOPATHOLOGICAL CLASSIFICATION

1.Adenomas2.Carcinomas3.Non-epithelial tumours4.Malignant lymphomas5.Secondary tumours6.Unclassified tumours


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3 % of head and neck malignant tumours80 % occur in parotid gland10 % occur in the submandibular gland

10 % occur in sublingual gland and the minorsalivary glandsBenign tumors are more common


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Sublingual 70%Submandibular 40%Parotid 20 %


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BenignPleomorphic adenoma 80%Monomorphic adenoma

AdenolymphomaOxyphil adenoma(oncocytoma)Others


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MalignantMucopidermoidAdenoid cysticAcinic cell caAdenoca


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MalignantEpidermoidCa in pleomorphic adenomaRare: squamous cell, undifferentiated ca


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40% of malignant tumours at all salivary types

Infiltrative growth

Marked tendency to invade nerve8% with Lnpathy at presentationMets-lungs


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Most common childhood tumour4-9 % of malignant tumoursComposed of epidermoid and mucous cells

Solid or cystic90% or more tumour cells-high grade40 % LNpathy


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2.5-4% of tumorsPredominantly parotidFrom terminal tubular intercalated duct

Maybe bilateralSlow growingLocal recurrence and mets after a long disease

free interval are common


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Malignant lymphomaUnclassified tumors


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1-3% in Head & Neck CancerSquamous cell carcinomaLymphoreticular tumors

EthesioneuroblastomaMinor salivary gland tumorsMelanoma


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Cause & Risk Factors - Environment- nickel refiners- petroleum refiners

- woodworkers- leather workers- textile workers

- Genetic


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Symptoms & Signs- Nasal obstruction- Bloody discharge

- Facial pain- Foul smell


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61st Annual General and Scientific Meetingof the NZ Society of ORL-HNS


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Baharudin Abdullah 1

Shamim Ahmed Khan1

Hillol K Pal 21 Dept of ORL-HNS, School of Medical Sciences, Universiti

Science Malaysia, 16150 K.Kerian, Kelantan, Malaysia2 Dept of Neuroscience, School of Medical Sciences,

Universiti Science Malaysia, 16150 K.Kerian, Kelantan,Malaysia


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A 50 years old man presented with a left sidednasal block and epistaxis for one year.A rigid endocopic examination showed a

whitish-reddish mass occupying the whole ofthe left nasal cavity.The mass was friable and bled on touch.


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The CT scan of paranasalsinus showed a largemass occupying the entireleft nasal cavityExtension into the leftmaxillary sinus anddestruction of the medialwall of the maxilla.

The mass was in contactwith the cribriform plate.


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There was also mildlateral bowing of theleft lamina papyraceaNo extension into theleft orbit was noted.There was noeffacement orasymmetry of fossa ofRosenmullar noted.


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A biopsy was taken from the intranasal mass.However, profuse bleeding occurred after thebiopsy which required nasal packing for 3

days.The biopsy showed an undifferentiatedcarcinoma.


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The tumor at the leftnasal cavity andadjacent to theanterior skull base/orbit was resectedusing an ultrasonicaspirator set at a

high frequencymode of 100 Hertz.


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The tip of the Dissectronultrasonic aspirator(Satelec Medical,Bordeaux, France) wascalibrated with the

Omnisight Image GuidedSystem (Radionics,Burlington,Massachusetts)Precise removal could be

performed without injuryof other structures at theskull base or the orbitalregion.


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The patient recovered well postoperatively.His hemoglobin remained between eleven totwelve g/dL.

He didnt require any blood transfusion or anyhematinics supplement.He did not have any CSF leak or any visualimpairment.


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Apply ultrasonic energyThe piezo electricityapplied to thesonotrode creates on

the target cells a linearvibration effect 30,000times a secondAchievingfragmentationthrough a mechanicalaction.


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FragmentationThe simultaneoususe of an irrigation

fluid begins toinduce theselectivity of thetarget cells.


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Generate selectivitySelective exeresis isachieved byintracellular cavitation

as a result of thecavitation in aqueoustissues and of thedifferent elasticity of thesurrounding tissues(nerves, blood vessels,tumor tissue).


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Aspirate the tissuesThe fragmentedtissues suspended in

the irrigation fluidare sucked up,leaving thesurrounding

structures intact.


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ENT Head and Neck Radiology Seminar16-17 July 2010

Hospital Ampang

1overview of head & neck tumours

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