Head and Neck Tumors with classification and management .pptx

This explains about various head and neck tumors and their management

1. Overview of Head and Neck Tumors Moderator: Dr. Helina (Consultant plastic and reconstructive surgeon) Presenter: Amina U (PRSR4) May, 2024 GC

2. Outlines Introduction Epidemiology Risk factors Pathophysiology Clinical evaluation Staging Management principles Management of specific sites 2

3. Introduction The term head and neck cancer relates to malignant tumors arising from the mucosal epithelium of the upper aerodigestive tract They have devastating consequences due to their impact on critical functions of respiration, alimentation and cosmetic implications Unfortunately, most patients present with late stage disease necessitating multimodality treatment, which increases the risk of subsequent complications, deformity, and dysfunction 3

4. UADT sites and subsites 4

5. Epidemiology Head and neck cancer is the 6th commonest type of cancer 650,000 new cases and 350,000 cancer deaths worldwide per year 3-5% of cancers but 22% of cancer related deaths M:F=2-4:1 Over 95% are squamous cell carcinoma Epidemiology is changing because of the increased incidence of HPV associated oropharyngeal SCC Young, nonsmokers 5

6. Risk factors Tobacco use (smoked and “smokeless”) – a major risk factor for UADT SCC Alcohol – independent risk factor and synergistic with tobacco Betel quid, areca nut UV exposure – lip cancers Leukoplakia and erythroplakia – premalignant lesions HPV – major etiologic factor in oropharyngeal SCC (2/3) EBV, salt-cured fish and meats rich in nitrosamines – NPC Other risk factors: poor oral hygiene, poor nutrition, irritation from dentures, occupational exposures, and genetic predisposition 6

7. Pathophysiology Mucosal SCC likely arises from adult stem or progenitor cells in the mucosal epithelium lining the UADT Invasive disease most commonly arises de novo Multiple carcinogens in tobacco reactive metabolites DNA injury Acetaldehyde (carcinogen in alcohol) – acts as a solvent for tobacco carcinogens “Field cancerization” – high incidence of synchronous and metachronous primary cancers seen in mucosal SCC HPV infects the squamous epithelium of the lingual and palatine crypts incorporates into cellular DNA transcription of E6 and E7 inactivate p53 and RB1 proteins 7

8. Clinical evaluation History – risk factors, comorbidities, previous surgeries or radiotherapy, social circumstances Painful or bleeding non-healing ulcers, hemoptysis, dysphagia, odynophagia, ear pain (oropharynx), hoarseness (hypopharynx), or nasal obstruction (nasopharynx), painless neck lump, weight loss PE – local extent of the primary tumor, functional impairment, n utritional assessment along with preoperative supplementation Fiberoptic endoscopy to inspect the nasal cavity, pharynx, base of tongue and larynx Dental assessment, cranial nerves, parotid, cervical lymph nodes CVS, respiratory and GI – distant metastases or medical issues 8

9. Investigation US – initial investigation CT scan – assess primary tumor and regional and distant metastasis, cervical lymph node status, bone invasion MRI – delineate disease extent, perineural invasion Endoscopy – assess tumors not detectable on PE, opportunity for biopsy PET scan – localization of unknown primary or synchronous tumor, occult cervical lymphatic disease, distant metastasis Metastatic workup – CXR, chest CT, PET scan, PET/CT FNAC – suspected lymph nodes 9

10. Staging AJCC staging system is a tool used to stage cancer prior to any treatment ( cTNM ), after surgical resection ( pTNM ), and at recurrence ( rTNM ) It helps to select best treatment option, plan the treatment, and estimate prognosis Modifications in the 8 th edition: addition of depth of invasion to the T status of oral cavity cancer inclusion of extranodal extension in N staging except in HPV associated oropharynx cancer and nasopharynx cancer separate section for HPV-positive oropharyngeal cancer separate section for nasopharynx 10

11. Staging 11

12. Staging 12

13. Staging 13

14. Management principles Multidisciplinary tumor board setting Goal: to find the optimal management plan for each patient 14

15. Management principles Preventative measures – reduce smoking and alcohol, HPV vaccine Stages I-II – single modality therapy (70–90% 5-year overall survival) Surgery Vs Radiation Stages III-IV – combined modality treatment Balance of treatment efficacy and the relative morbidity of the different treatment modalities at each tumor site The modality used to treat the primary tumor is generally also used to manage the neck 15

16. Management principles Adjuvant treatment is necessary to improve locoregional control in those with high(*)/ intermediate risk clinicopathologic features: *Involved (<5 mm) pathological margins * Extranodal extension (ENE) T3–4 primary tumor stage Perineural invasion Lymphovascular invasion Two or more involved lymph nodes (>N2) 16

17. Follow up Regular post-treatment follow-up identify treatment failure and recurrent and metachronous tumors 80–90% of recurrences – in th e first 2-4 years post-treatment P ost-treatment CT or MRI is performed at 6 weeks to evaluate the outcome of treatment and provide baseline imaging Then routine ongoing follow-up scans at the clinician’s discretion Lifelong follow up 17

18. Treatment principles per anatomical subsite 18

19. The oral cavity Boundaries: lip vermilion to the hard–soft palate junction and circumvallate papillae anterior tonsillar pillars and glossotonsillar folds laterally 7 subsites: lip, floor of mouth, oral tongue, buccal mucosa, hard palate, dentoalveolar ridge, and retromolar trigone lower lip, lateral oral tongue – commonest sites 19

20. The oral cavity Make up 14% of all head and neck cancers 55% of these patients present with early stage disease Most common cancer of the oral cavity is SCC (>90%) less commonly salivary gland tumors and sarcoma Staging is the most important determinant of prognosis overall 5-year survival: localized disease - 84% lymph node metastasis - 65% distant metastasis - 39% 20

21. Subsites Lip – most common site of head and neck ca related to sun exposure, pipe smoking The oral tongue – commonest intraoral site, mostly along the lateral border of the middle 1/3 The buccal mucosa – rare site, <10% of oral cavity cancers Floor of mouth – challenging area to both assess clinically and to resect with clear margins The dentoalveolar ridges, hard palate, and the retromolar trigone – a small percentage early invasion of the mandible or maxilla 21

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24. The oral cavity – management Surgery is the preferred primary treatment modality 1cm clinical margin, 1–2cm radial margin Mandible – marginal resection (periosteum only or minimal cortical involvement), segmental resection (medullary invasion) Radiotherapy – primary or adjunct Adjunct chemoradiotherapy – incomplete resection margins or ENE 24

25. The oral cavity – management Elective neck dissection for the clinically N0, if primary tumor DOI >5mm improved pathological staging and a 12.5% improvement in overall survival include ipsilateral levels I–III, including at least 18 lymph nodes bilateral if the lesion is midline or a T3/4 oral tongue or FOM SCC 25

26. Surgical approaches to the oral cavity Most oral cavity cancers not involving the mandible can be accessed transorally R esults in minimal morbidity for the patient and is the preferred approach where possible On occasion, the upper lip may need to be split and connected to a lateral rhinotomy incision (i.e., the Weber–Ferguson incision) Transoral and facial approaches may be combined in the midface 26

27. Weber–Ferguson incision 27

28. Combined transoral and facial approaches 28

29. Management of the mandible Tumors of the dentoalveolar ridges, floor of mouth, and retromolar trigone Metastatic neck disease in level 1 Marginal mandibulectomy – tumors that abut but don’t invade mandible or tumors that only superficially invade the bony cortex Segmental mandibulectomy – significant invasion of the mandibular cortex, involvement of the marrow space, or paresthesia of the mental nerve suggesting inferior alveolar nerve involvement 29

30. Marginal mandibulectomy 30

31. Segmental mandibulectomy 31

32. Oropharynx cancer Extends from the level of the hard palate superiorly down to the tip of the epiglottis inferiorly Subsites : palatine tonsils – 60% base of tongue – 25% soft palate – 10% pharyngeal wall – 5% HPV-associated oropharyngeal cancer Young males, no smoking or alcohol Hx 3-year overall survival is 93% Vs 46.8% 32

33. Oropharynx cancer treatment The demographics, evaluation, and treatment of patients with oropharynx cancers have changed dramatically in the last decade Early stage – surgical resection of well-delineated lesions can be curative with minimal morbidity Advanced stage – radiation and chemotherapy as curative treatment as part of an organ preservation approach traditional standard therapy - composite surgical resection with postoperative radiation surgical resection is not favored due to the potential magnitude of functional debilitation 33

34. Surgical approaches to the oropharynx Open surgical approaches – mandibulotomy or transcervical associated with significant morbidity non-surgical treatment of oropharyngeal malignancies became increasingly common Radiotherapy – intensity modulated radiation therapy (IMRT) early and late effects of radiation can significantly impair a patient’s quality of life Transoral approaches – transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) return to a normal diet more quickly, less likely to require free flap reconstruction, and shorter hospital stay similar oncologic outcomes to primary radiotherapy a difference in adverse event profile 34

35. Open surgical approaches to the oropharynx 35

36. Larynx and hypopharynx cancer Larynx extends from the tip of the epiglottis to the inferior border of the cricoid cartilage Supraglottis Glottis – area of lymphatic watershed Subglottis Hypopharynx wraps around the posterior larynx Piriform fossa Posterior pharyngeal wall Post-cricoid region 36

37. Treatment of larynx and hypopharynx cancer Early laryngeal cancers – TLM or radiation therapy similar oncologic control rates: >85% 5-year locoregional control and overall survival open partial laryngeal surgery – for patients who refuse radiotherapy and have poor endoscopic access precluding TLM Advanced laryngeal cancer Previously – total laryngectomy followed by radiation therapy Comparison of induction chemotherapy followed by radiotherapy in patients who had a partial or complete response Vs surgery followed by radiation Survival similar for both groups at 2 years but study group had the benefit of keeping their larynx 37

38. Treatment of larynx and hypopharynx cancer Advanced laryngeal cancer Comparison of radiotherapy alone, concurrent chemoradiotherapy, and induction chemotherapy followed by radiotherapy Overall survival similar in all groups Concurrent chemoradiotherapy group had the highest rate of larynx preservation and locoregional control - hence standard non-surgical therapy for advanced laryngeal cancer The neck should always be treated electively in supraglottic tumors and hypopharynx cancers, by way of the modality used to treat the primary site. 38

39. Treatment of larynx and hypopharynx cancer Surgery – gold standard surgical management of advanced laryngeal cancer is total laryngectomy involvement of the laryngeal cartilages pre-treatment laryngeal dysfunction salvage of persistent or recurrent disease Removal of the airway from above the hyoid to the upper tracheal rings Permanent tracheostomy Pharynx is closed primarily to allow near-normal swallowing Voice rehabilitation – trachea-esophageal valve speaking prosthesis 39

40. Summary Head and neck cancer relates to malignant tumors arising from the mucosal epithelium of the upper aerodigestive tract Majority (>95%) are SCCs Tobacco and alcohol are the major risk factors Single modality therapy for early stage tumors and; combined modality treatment for advanced stages 40

41. References Neligan - vol 3 PRS, Craniofacial, Head and Neck Surgery, Pediatric Plastic surgery, 4 th edition Neligan - vol 3 PRS, Craniofacial, Head and Neck Surgery, Pediatric Plastic surgery, 5 th edition Head and Neck Cancer – Multimodality Management Grabb and Smith’s Plastic Surgery, 8th edition AJCC, 8 th edition 41