oral cavity and oropharyngeal cancer · 2016-08-23 · oral cavity and oropharyngeal cancer wendy...
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Oral Cavity and Oropharyngeal Cancer
Wendy R. K. Smoker, MS, MD, FACR
Professor Emeritus-Neuroradiology
University of Iowa Hospitals and Clinics
I have no relevant financial relationships with commercial interests
NEXT 25 MINUTES
ABSOLUTELYNOTHING!
Learn common pathways of “spread” of oropharyngeal and oral cavity SCCa.
Educational Objectives
Learn the most common sites of oropharyngeal and oral cavity SCCa.
Review common nodal drainage patterns of oropharyngeal and oral cavity SCCa.
Recognize features that upstage primary tumors to T4a (moderately advanced) and T4b (very advanced) local disease.
Stage 0: Tis N0 M0Stage I: T1 N0 M0Stage II: T2 N0 M0Stage III: T3
T1-3N0N1
M0M0
Stage IVA: T4aT1-4a
N0-1N2
M0M0
Stage IVB: T4bAny T
Any NN3
M0M0
Stage IVC: Any T Any N M1
N1: Single ipsilateral node <= 3 cmN2a: 3 cm < Single ipsilateral node <= 6 cmN2b: Multiple ipsilateral nodes <= 6 cmN2c: Bi- or contralateral node(s) <= 6 cmN3: Node > 6 cm
T1: Tumor <= 2 cmT2: 2 cm < Tumor <= 4 cmT3: Tumor > 4 cm or extension to lingual surface of epiglottisT4a: Moderately advanced local disease: Involvement of larynx, extrinsic tongue
muscles, medial pterygoid, hard palate, or mandibleT4b: Very advanced local disease: Involvement of lateral pterygoid, pterygoid plates,
lateral NP, BOS, or carotid artery encasement
Oropharyngeal Carcinoma Staging (Tonsil and Base of Tongue)
Size MATTERS
AJCC, 7th edition
Tonsillar SCCa: What to Report
• Tumor size?
• Involvement of structures/spaces that will upstage the primary tumor:
• T4a: Larynx, ext tongue mm*, med pterygoid m, hard palate, mandible
• T4b: Lat pterygoid m, pterygoid plates, lateral NPhx, BOS, ICA (CS)
• What is the status of regional lymph nodes(58-76%)? Levels I-V
• Also should report involvement of soft palate, base of tongue, oral tongue…
Radiology 205:629-646, 1997
Mucosa over ATP (palatoglossus m): most common site of OP SCCa
*Genioglossus, hyoglossus, palatoglossus, styloglossus
Size? Larynx? SPal/HPal? NPhx? BOT/OT? MandExt mm?CS?MS?Nodes?
3 cmNY-SPalNNNNNNY-IIa
MD Tonsillar SCCa (p16+)64M: Globus discomfort in posterior throat
T2N1M0=III SUV = 13.3
Size? Larynx? SPal/HPal? NPhx? BOT/OT? Mand? Ext mm?CS?MS?Nodes?T2N2cM0=IVA
3 cmNNNNNNNNY-Bilat
MD Tonsillar SCCa61M: Bilateral enlarging neck masses
51M: Rt neck swelling, oral cavity “sore”, 15 lb wt loss in 2 months
Size?Larynx? SPal/HPal?NPhx?BOT/OT?Mand?Ext mm?CS?MS?Nodes?
2.5 cmNY-SPalNY-BOTNYNNY-3.2cm
PD Tonsillar SCCa (p16+)
Ulceration
Nl hyoglossus
T4a (ext mm) N2a (3.2 cm) M0 = IVASUV = 16.0 SUV = 17.0
Size? Larynx? SPal/HPal?NPhx?BOT/OT?Mand?Ext mm?CS?PPS?MS?Nodes?
T4b (lat NPx) N1M0=IVB
4.7 cmNY-SPalYNNNNNNY-IIA
MD Tonsillar SCCa
Size? Larynx? SPal/HPal?NPhx?BOT/OT?Mand?Ext mm?CS?PPS?MS?Nodes?
5.5 cmNY-SPalYNNNNNNY-IIA, RPS
PD Tonsillar SCCa (p16+)
T4b (lat NPhx) N2cM0=IVB
43M: Pain, trouble swallowing, voice changes, and otalgia
Also had PD SCCa in Rt tonsil
BOT Carcinoma-What to Report• Tumor size?
• Extension across the midline?
• Involvement of structures/spaces that will upstage the primary tumor: T4a: Larynx, ext tongue mm, med pterygoid m, hard palate, mandible
T4b: Lat pterygoid m, pterygoid plates, lateral NPhx, BOS, ICA (CS)
• What is the status of regional nodes (50-83%)? Levels II-V
• Should also report extension to oral tongue, FOM, SLS, tonsil/soft palate along GTS…
Radiology 205:629-646, 1997 T2N1M0=III
Size? Xs midline?Tonsil?SPal/HPal? OT? Ext mm?FOM/SLSLarynx?CS?MS?Nodes?
3.5 cmNYNNNNNNNY-IIA
This case is included to show extension to the ant tonsillar pillar via the glossotonsillar
sulcus on PET
BOT Carcinoma
T4a (ext mm) N1=IVA
Size? Xs midline?Tonsil? SPal/HPal? OT? Ext mm?FOM/SLS?Larynx?CS?MS?Nodes?
Ulceration
Ulceration
Normal mylohyoid m
Normal mylohyoid m
Normal hyoglossus m
3.5 cmNYNNY*Y-FOMNNNY-IIA
BOT Carcinoma
T4a (ext mm) N0M0=IVA
Size? Xs midline?Tonsil? SPal/HPal? OT? Ext mm?FOM/SLSLarynx?CS?MS?Nodes?
4.3 cmYYY-SPalYY*YNNNN
BOT Carcinoma
Hyoglossus
Genioglossus
SUV = 10.5
55F: 50 lb wt. loss, dysphagia, odynophagia, trismus, Rt otalgia, Rttongue deviation, and dysarthria
Size? Xs midline?Tonsil? SPal/HPal? OT? Ext mm?FOM/SLSLarynx?CS?MS?Nodes?
4.2 cmNYNNNNY?YY (MP)Y*
PD BOT Carcinoma (p16+)
T4b (CS involvement) N2bM0=IVB
*Conglomerate nodal mass
Oral Cavity Carcinoma Staging• TX: Primary tumor (T) cannot be assessed• T0: No evidence of primary tumor• Tis: Carcinoma in situ • T1: >/= 2 cm in greatest dimension• T2: Tumor 2 to 4 cm• T3: Tumor more than 4 cm• T4a: Moderately advanced local disease (more
than superficial erosion)Lip: Invades through cortical bone,
inferior alveolar nerve (PNT), FOM, skin of face (chin or nose).
Oral cavity: Invades adjacent structures only (e.g. through cortical bone into deep (extrinsic) tongue muscles, maxillary sinus, or skin of face)
• T4b: Very advanced local disease. Invades the masticator space, pterygoid plates, skull base and/or encases the ICA.
• NX: Regional Lymph nodes cannot be assessed
• N0: No nodes• N1: Single, ipsilateral, < 3cm• N2a: Single, ipsilateral, 3 to 6 cm• N2b: Multiple ipsilateral, < 6 cm• N2c: Bilateral or contralateral, < 6 cm• N3: > 6 cm
• Stage 0: Tis, N0, M0• Stage I: T1, N0, M0 • Stage II: T2, N0, M0 • Stage III: T3, N0, M0
T1, N1, M0T2, N1, M0T3, N1, M0
• Stage IVA: T4a, N0, M0 T4a, N1, M0T1, N2, M0T2, N2, M0T3, N2, M0T4a, N2, M0
• Stage IVB: T4b, any N, M0Any T, N3, M0
• Stage IVC: Any T, Any N, M1
AJCC, 7th edition
NODES
Oral Cavity Carcinoma Sites
• Lower lip 38 %• Oral tongue 22 %• Floor of the mouth 17 %
• Gingiva/RMT * 6 %• Hard Palate 5 %• Upper lip 4 %• Buccal mucosa 2 %• Other 5.5 %
* Includes retromolar trigone Ca because natural history, anatomic relationships, and management are closer to lesions of the gingiva than anterior tonsillar pillar
Lower Lip Carcinoma-What to Report
• Size?
• T4a: Skin of face, cortical bone (mand), FOM involved, *Perineuraltumor spread (PNTS): mental n inferior alveolar n V3?
• T4b: MS, ptery plates, BOS, ICA
• Intracranial extension (ICRAN ext)?
• Lymph nodes? Levels I and IIRadiology 205:629-646, 1997
Although it is the most common site for SCCa (38%), these lesions rarely require imaging evaluation.
T1N2bM0=IVA(very small primary tumor but already stage IVA due to nodal
disease)
Size?Skin?Mand?PNTS?FOM ext?MS ext?ICRAN ext?Nodes?
1.5cmNNNNNNY-IB/IIA
Lower Lip Carcinoma
Size?Skin?Mand?FOM ext?PNTS?MS ext?ICRAN ext?Nodes?
3cmNYNY*YNN (9mm)
T4a (PNTS-Inf Alv n) N0M0=IVA
WD Lower Lip Carcinoma 80F: Rock hard lip mass and Rt chin numbness
Fat in normal Inf Alv Canal
Lower Lip Carcinoma
Courtesy M Michel, MD
Size?Skin?Mand?FOM ext?PNTS?MS ext?ICRAN ext?Nodes?
>4cm!YYYYYY-V3N
T4bN0M0=IVB
Tumor exiting Inferior Alv canal
Tumor exiting Inferior Alv canal
Tumor exiting Inferior Alv canal
Oral Tongue Carcinoma
• Relationship to midline fibrofatty septum. Clear surgical margin if tumor abuts or crosses the midline would not be possible without total glossectomy which is functionally crippling. These patients usually undergo non-surgical management.
• Relationship to the sublingual space where the neurovascular bundle (NVB) of the tongue is located. Sacrifice of one NVB with tumor but leave a small pedicle attached to the contralateral NVB. However, if both NVBs are involved, the situation remains as above for contralateral disease.
Two most important findings in relation to the primary tumor that impact treatment and prognosis are:
Oral Tongue Carcinoma-What to Report
Radiology 205:629-646, 1997
• Tumor size? • Midline crossed (X ML)?• T4a: Cortical bone (mand), extrinsic
tongue muscles (Ext mm), FOM/SLS, skin of face
• T4b: MS, ptery plates, BOS, ICA (CS)
• Nodal involvement? (34%-65%) Levels I-III
• Should also assess extension to BOT, tonsil and soft palate
67F: Rt tongue soreness, Rt. otalgiaSize?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?
2.5cmNNYYNNNN
Nl mylohyoid m
Nl SLS
PD Oral Tongue Carcinoma
T2N0M0=II
Size?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?
60M: Rt tongue “ulcer” x 2 months
MD Oral Tongue Carcinoma (p16+)
4.0cmYNNNNNNN
T3N0M0=III
32F: Painful tongue ulceration x 3 yrs; 40lb weight loss; new otalgia
Size?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?
5.5cmYYYYNYNY-IIA
MD Oral Tongue Carcinoma
T4a (ext mm) N1M0=IVA
Genioglossus
Size?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?
5 cmAbutsYYYNYNY-IIA
Nl mylohyoid m
Nl mylohyoid m
Oral Tongue Carcinoma
T4a (ext mm) N1M0=IVA
Nl SLS
Size?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?
6.8 cmAbutsYYYNYYN
MD Oral Tongue SCCa60F: Left tongue pain and otalgia x 6 months
Nl hyoglossus
?
?
1/2 T4a (ext mm) N0M0=IVA??
2/2
Now see involvment of:Mast Space Lat pterygoid musclePPF/V2V3 in f ovale
Stage IVB
• Tumor size? • Midline crossed (X ML)?• T4a: Cortical bone (mand), oral
tongue (OT), extrinsic tongue muscles (Ext mm), SLS, skin of face
• T4b: MS, ptery plates, BOS, ICA (CS)
• Nodal involvement? (30%-59%) Levels I-II
Floor of Mouth Carcinoma-What to Report
Radiology 205:629-646, 1997
One of the earliest findings of SLS involvement by these tumors may be submandibular duct obstruction!
49M; FOM tenderness; 1/5 vodka/day,100 pack years
Size?SLS?X ML?Mand?Oral tongue?Ext mm?BOT?Tonsil?Nodes?
2.5.cmY-RtYNNNNNN
Dilated Wharton duct
Dilated Wharton duct
T2N0M0=II
Floor of Mouth Carcinoma
T2N1M0=III
Nl SLS Nl SLS Size?SLS?X ML?Mand?Oral tongue?Ext mm?BOT?Tonsil?Nodes?
2.5.cmY-RtNNNNNNY-IB
Dilated Wharton duct
Floor of Mouth Carcinoma
*Cortical mandibular erosion
Size?SLS?X ML?Mand?Oral tongue?Ext mm?BOT?Tonsil?Nodes?
3.5cmYAbutsY*YYNNN
Nl SLS
Dilated Wharton duct
Floor of Mouth Carcinoma
T4a (ext mm) N0M0=IVA
The Pterygomandibular Raphe (PMR)
• Thickening of the buccopharyngeal fascia
• Gives origin to the buccinatorand superior constrictor muscles
• Extends from hamulus of the med ptery plate to posterior aspect of the mylohyoid line
• A potential pathway for disease spread from OC & OP to BS, MS, NP, FOM…
• Extension alongpterygomandibular raphe(Buccinator or superior constrictor muscles)??
• Extension to masticator space (MS), maxilla, base of skull (BOS)?
• Extension to floor of mouth (FOM), mandible (mand)?
• PNTS?
• Nodes involved? (39%-56%) Levels I-III
Retromolar Trigone Carcinoma-What to Report
Radiology 205:629-646, 1997
T1N1M0=III
63M: Unknown SCCa primary (neck node)Size? Bucc m?SPC m?MS ext?Maxilla?BOS?Mand?PNTS?FOM?Nodes?
1.5cmNNNNNNNNY-IIB
RMT Carcinoma
T4a (MS) N0M0=IVA
Normal buccinator m
Normal SPC m
RMT Carcinoma
Size? Bucc m?SPC m?MS ext?Maxilla?BOS?Mand?PNTS?FOM?Nodes?
1.5cmYYYNNNNNN
T4a (*) N0M0=IVA
Size? Bucc m?SPC m?MS ext?Maxilla?BOS?Mand?PNTS?FOM?Nodes?
>4 cmYNYY*NY*Y*NN
Dilated Stenson duct
Normal buccinator m
Normal mandibular marrow
*Tumor extends along PMR with PNTS into inferior alveolar canal
RMT Carcinoma