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Introduction. Head and neck cancer is remarkable for its ability to cause extensive local tissue destruction and regional node involvement in the absence of distant metastasis. Introduction. Tumours are usually confined to the primary sites Regional nodes
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1. Tumours of the head and neck
2. Introduction Head and neck cancer is remarkable for its ability to cause extensive local tissue destruction and regional node involvement in the absence of distant metastasis
3. Introduction Tumours are usually confined to the primary sites
Regional nodes & haematogenous metastasis are very rare and late in the disease process
Loco-regional treatment by either surgery, radiotherapy or combination of the two is frequently curative
4. Introduction Many of the oral lesions may have had an initial lesion that were potentially curable.
The cure could be predicted if the lesion is diagnosed early and the appropriate therapy is given before the disease reaches advance stages to become incurable
5. Introduction Cancer of the oral cavity in Saudi Arabia is not an uncommon disease
It account for more than 25% of all malignancies, in the Southern region, it might reach up to 35%
In males, it is third in frequency following lung and prostate cancer
In females, it is second following breast cancer
6. Introduction The spectrum of malignant tumours to affect the oral cavity vary widely and includes:
Surface epithelium
Squamous cell carcinoma over 90%
Glandular epithelium
Adenocarcinomas in females
Mucoepidermoid carcinomas in males
Mesenchymal tissues
Lymphomas, Sarcomas are very rare
7. Introduction Surface Epithelium
1- Squamous cell Carcinoma
Undifferentiated carcinoma
Differentiated carcinoma
Adenoid squamous carcinoma
Verrucous carcinoma
2- Basal cell carcinoma
3- Malignant Melanoma
8. Introduction Glandular epithelium
1- Adenocarcinoma
2- Mucoepidermoid carcinoma
3- Adenoid cystic carcinoma
4- Acinic cell carcinoma
5- Undifferentiated carcinoma
9. Introduction Mesenchymal tissues
Sarcoma
Fibrosarcoma
Rhadomyosarcoma
Osteogenic sarcoma
Chondrosarcoma
Neurogenic sarcoma
Angiosarcoma
Synovial cell sarcoma
Hodgkin’s & non-Hodgkin’s lymphomas
Plasmacytoma & multiple myeloma
Leukaemia
Metastatic carcinoma, sarcoma
10. Introduction Prognostic Indicators:
Sex: Poor prognosis in females
General condition & health status of patient
T stage
Number of histologically positive nodes
Surgical margin status
Type of therapy and blood transfusion
11. Introduction Aetiology:
Smoking
Alcohol consumption
They have synergistic role
Burning tar gives off a variety of active substances e.g. benzopyrene, methyl cholanthrine, which will be broken by arylhydrocarbon hydroxylase into epoxide, carcinogen, that bind to the DNA
Snuff dipping and Shama user
12. Introduction Aetiology Chronic irritation from sharp jagged teeth
Chemicals:
Asbestos, Nickel-Chromate, in nasal and paranasal sinuses tumours
Wood dust in Adenocarcinoma of the nose
Dietary factors:
Vitamin A deficiency
Vitamin B deficiency, Patereson-Kelly syndrome
Radiation exposure
Viruses:
Human Papilloma Virus HPV
Epstein-Barr Virus EBV
Human Immunodeficiency Virus HIV
Hepatitis virus
13. Introduction Acquired capability of cancer cell:
Limitless replicative potential
Evading apoptosis
Self-sufficiency in growth signal
Insensitive to antigrowth signals
Sustained angiogenesis
Tissue invasion and metastasis
14. Assessment Clinical Examination:
Tumours, when first seen, are almost always confined to the head and neck with no distant metastasis
Head and neck tumours are rarely irremovable, all structures can be removed with the tumour in continuity and repaired later
The majority of cases are potentially treatable
15. Assessment Whether to treat or not depend on:
the age
the health status of the patient
advance stage
local disease
16. Assessment Full assessment will lead to one of the following conclusions:
Patient is potentially curable
Primary tumour is curable but patient develop another illness
Patient is incurable but should be treated
Patient is incurable and should not be treated
17. Assessment History:
Age:
Patient are generally over 45 years.
Tumours affecting younger age group are usually sinister, defective immunological make-up
Most tumours are of epithelial origin and they require years of abuse by smoking and tobacco
Tumours in younger patients, who do not smoke, is usually very sinister
Tumours developing in an immuno-compromised patients do not respond to any treatment modality
18. Assessment Complaint:
Vary widely and is often unreliable
Painless lump which persisted for a varying period of time
Persistent ulceration
Difficulty of wearing denture
Later Symptoms:
Pain locally or referred to the jaw or ear
Difficulty with chewing food and swallowing
Altered speech and respiratory difficulty
Asymptomatic and noticed during routine dental examination
19. Assessment The patient general condition:
Assessed with full investigation and classified for performance status
Grade 0 Fully active without restriction
Grade 1 Ambulatory but restricted in physically strenuous activity
Grade 2 Ambulatory but unable to carry out any work activity
Grade 3 Confined to bed but capable of limited self care
Grade 4 Confined to bed and unable to carry out any self care
Karnofsky Status
20. Assessment Examination:
Think in term of T Staging, delineate its border by inspection and palpation
Record and draw the lesion from different angles using normal anatomical landmarks
The status of teeth should be assessed as causative and if radiotherapy is to considered
21. Assessment Staging of cancer:
Subdividing the malignant lesion into groups with similar behaviour
Act as a guide to appropriate treatment
Act as a guide to prognosis
Permits more reliable comparison of results
Primary site:
Histological type, size and extend of the primary
Node metastasis
Haematogenous metastasis
22. Staging Primary Tumour:
Indicated by the letter T and the suffix 1,2, 3 or 4 represent more advancing disease
T1 – tumour 2 cm or less
T2 – tumour more than 2 but less than 4 cm
T3 – tumour more than 4 cm
T4 – Tumour more than 4 cm with deep invasion of underlying tissues
T0 – No evidence of primary tumour
Tis – Carcinoma in Situ
TX – Extend of primary tumour cannot be assessed
23. Staging Lymph node:
Is used to describe progressive lymph node involvement
N1 – Single epsilateral nodes 3 cm or less in diameter
N2 – Single epsilateral nodes more than 3 cm but less than 6 cm, or multiple clinically positive epsilateral less than 6 cm
N2a – Single
N2b – Multiple
N3 – Clinically positive epsilateral more than 6 cm, Bilateral or contralateral
N3a – Epsilateral more than 6 cm
N3b – Bilateral, each side staged separately
N3c – Contralateral only
24. Staging Distant metastasis:
M0 – No metastases present
M1 – Metastases clinically demonstrable
MX – Metastases cannot be assessed
25. Staging TNM Staging:
Stage I: T1, N0, M0
Stage II: T2, N0, M0
Stage III: T3, N0, M0
T1, 2 or 3, N1, M0
Stage IV: T4, N0 or 1, M0
T1 – 4, N2 or 3, M0
T1 – 4, N1 – 3, M1
AJCC 1983
26. Staging Stage I
compromise negative nodes and operable primary
Stage II
operable primary with operable nodes
Stage III
inoperable due advanced primary or advanced nodal involvement
Stage IV
Distant metastases preclude any surgical intervention
27. Surgical anatomy The Lip:
Covered with non-keratinized stratified squamous epithelium which is transparent, appear red, and contain no hair, sebaceous gland or pigments
On the vermilion border it closely cover the orbicularis oris muscle but on the lingual side mucous gland is present within the muscle and mucosa
The epithelium is 2 mm away from the muscle, ulcerative lesions will be fixed early in the disease
28. Surgical anatomy The Lip Lymphatic drainage:
Mucosal and cutaneous systems.
Lower lip:
One medial trunk which drain the inner third of the lip into the submental group
Two lateral trunk which drain the outer two-third into the submandibular lymph nodes
Anastomosis account for bilateral metastases
Upper lip:
Drain into the periauricular, parotid, submandibular and submental lymph nodes
29. Surgical anatomy The Lip Age and sex:
The sixth decade and Male : female ratio is 80:1
93% affect the lower lip with squamous cell carcinoma, exophytic type
5% in the upper lip and commonly basal cell carcinoma, commoner in females
Solar exposure, more radiation on the lower lip
Commoner in fair complexion
Smoker mainly pipe
In the upper lip, SCC metastasizes earlier than lower lip
30. Surgical anatomy The buccal mucosa:
Covered with non-keratinizing stratified squamous epithelium with multiple minor salivary glands
It is tight over the buccinator muscle and fixed to the upper and lower sulci
Lymphatic drainage:
The submandibular lymph nodes to the lower deep cervical chain
31. Surgical anatomy The tongue:
Specialized keratinized epithelium with collection of minor salivary gland and muscle fibres
The interlacing muscle fibres form an easy pathway for cancer spread and the constant movement of the tongue disseminates the disease widely
Excision should be wide with 2 cm safe margin
32. Surgical anatomy The tongue A disease of the middle age and elderly with equal sex incidence
85% occurs in the lateral border of the anterior 2/3 while tip, dorsum and ventral surface are rarely involved
The lesion may be infiltrative (small on the outside but palpation shows deep invasion) or exophytic and usually of the well-differentiated type
33. Surgical anatomy The tongue Lymph drainage:
Tip of the tongue:
To the submental lymph nodes – to the lower deep cervical chains
The anterior 2/3:
the lower deep cervical chains – jugulo-omohyoid nodes
Suprahyoid block dissection of no value
The posterior 1/3:
drain to the upper deep cervical chains
The tip and middle part of the tongue have rich bilateral capillary network but less in the lateral margins
The U-shaped floor of the mouth drain to the submandibular lymph nodes
Bilateral drainage from the anterior part of the U
34. Surgical anatomy The floor of the mouth:
Anterior medial part:
Commoner than the lateral part
Spread medially into the ventral surface of the tongue and laterally
Deep spread to the base of the tongue and the hyoglossus and genioglossus muscles
Shows bilateral lymphatic spread to the submandibular and the submental nodes
35. Surgical anatomy The floor of the mouth Lateral part:
Spread medially to the side of the tongue
Lateral spread to the alveolar ridge where presence or absence of the teeth govern the outcome:
Teeth act as a barrier against buccal spread
In edentulous patient, the alveolar process has resorbed and cortex is incomplete, tumour reaches the cancellous spaces and the canal and spread through the nerve.
Deeper spread, mylohyoid muscle act as a barrier anteriorly, posteriorly the floor is close to the skin, appear as a palpable lump in the submandibular area
36. Surgical anatomy The mandible:
Carcinoma of the lower alveolus affects the antero-lateral part and spread to the floor of the mouth
Tongue and floor of the mouth tumours reach the lower alveolus by marginal spread in the mucosa and submucosa overlying the sublingual, submandibular glands and the mylohyoid muscle.
37. Surgical anatomy The mandible They act as barrier against deep infiltration
Alveolar bone above the mylohyoid line is initially affected
Edentulous jaws, mylohyoid line is on the occlusal ridge and the loss of the cortical bone barrier will allow tumour to spread downward into the medullary cavity
38. Surgical anatomy The mandible The inferior alveolar nerve provide a pathway for perineural spread in a predominately proximal direction with little involvement of the bone
Nerve looks clinical normal till late
Spread is not continuous, multiple pathological samples is required
Lymphatic spread to the submandibular lymph nodes
39. Surgical anatomy The hard palate:
Common location for carcinoma of the minor salivary gland
Presented as smooth, rounded, bulging masses
Squamous cell carcinomas present as ulcerative or exophytic lesion
Invade the bone at an early stage
Involve the nasal cavity and the antrum
Metastases to submandibular and upper deep cervical chains
Disease of the elderly (60 – 70 years)
More commoner in men
40. Surgical anatomy The maxillary sinus:
The sinus is related to the orbit, nose, alveolar process, infratemporal fossa and nasopharynx.
It has an outlet to the nose, ethmoid sinuses and the root of the teeth
The posterior ethmoidal air cell is separated from the optic nerve by a bar of bone but it is missing in 10% of cases and only encased in a sheath of dura, extension into the brain.
41. Surgical anatomy The maxillary sinus The inferior orbital fissure provide a route for entry of tumours into the orbit, the periostium offer an excellent resistant barrier to spread into the orbit
The roots of the upper premolars and molars and the alveolus are in intimate contact to the floor
The infratemporal fossa is the space behind the maxillary antrum and it connects to the para-pharyngyeal space, and the sphenoid bone superiorly with foramen spinosium and ovale with their emerging nerves
42. Surgical anatomy The maxillary sinus Lymphatic drainage:
Not fully understood
Drain posteriorly to the retropharyngeal nodes
Directly to the jugulo-digastric nodes
If it cross to the nose or the cheek it will drain to submandibular lymph nodes
Aetiology:
Wood dust, nickel, shoe factory and mustard gas
Snuff is a contributing factor
43. Surgical anatomy The maxillary sinus Classification
T1 - confined to the mucosa of the infrastructure
T2 - confined to the mucosa of the suprastructure without bone destruction - confined to infrastructure mucosa with bone destruction of medial and inferior wall only
T3 - More extensive tumour invading the cheek, the orbit, anterior ethmoid and pterygoid muscle
T4 – Invading the cribriform plate, posterior ethmoid and sphenoid sinuses, nasopharynx, pterygoid plat and the base of the skull
44. Surgical anatomy The maxillary sinus Malignant tumours:
Squamous cell carcinoma:
50% of all malignant lesions of the sinus
Bone destruction and invasion of nose, ethmoid, orbit, anterior wall and cheek, and palate or alveolar ridge and buccal sulcus
Adenocarcinoma:
Uncommon, occurs in people working in wood industry
Histologically two types, high or low grade
Invade bone and present the same way like SCC
Adenoid cystic carcinoma:
Shows as solid areas of cells instead
Distant metastasis and perineural invasion, infra-orbital, maxillary, greater palatine and olfactory nerves
45. Diagnostic Techniques Tissue Biopsy:
This is the mainstay of tumor diagnosis coupled with high degree of suspicion
Fine needle aspiration:
A 22-gauge needle attached to small volume syringe
Smear is prepared and stained after fixation with alcohol
Minimize tumor spillage and sample error in small lesion
46. Diagnostic Techniques Toluidine blue vital staining:
Acidophilic metachromatic nuclear stain that colors sites of squamous cell carcinoma but not adjacent normal mucosa surfaces
1 – 2% applied to dry surfaces and the dye diffuse into tissue through the large intercellular canaliculi
47. Diagnostic Techniques Incisional:
Small portion of the lesion with the adjacent normal tissues to facilitate correct diagnosis
To visualize the transitional zone between tumor and normal tissue
Performed at the periphery to avoid the necrotic central area
Excisional:
Removal of the entire lesion
Done as a primary treatment
48. Surgical anatomy Radiography:
Routine X-Ray studies:
Useful in cases of bony involvement
Panoramic views shows lytic lesions
Lateral soft-tissue films shows the extend into the nasopharynx or hypopharynx
Angiography:
Define oral malignancy – mainly avascular
Shows the relation to major vessels prior to surgery
Selective transcatheter embolization for bleeding control or decreasing tumor vascularity preoperatively
49. Diagnostic Techniques Sialography:
Cannulation of parotid and submandibular ducts and the infusiopn of contrast material
CT-Scan:
Define the gross limits and determine the actual depth of tumor
Evaluate adjacent bony structures and erosions involving the paranasal sinuses, base of skull and the cervical spine
Magnetic Resonance Imaging:
Gives a better resolution for soft tissue tumors
50. Diagnostic Techniques Nuclear Scanning:
The use of tumor-seeking radiopharmaceutical material
Bone scanning:
Uses Technetium 99-labeled phosphate complexes
Very sensitive and positive in the presence of bony lesions before their detection by conventional radiographs
Lacks specificity, infection, inflammation and even trauma result in positive scan
51. Diagnostic Techniques Salivary gland scanning:
I.V. Technetium shows an increased uptake in papillary cystadenoma.
Might occur with other benign or malignant tumors as a focal areas
Gallium-67 scanning:
Gallium isotopes concentrate in a rapidly growing tumors
Best in epidermoid carcinomas and lymphomas
Used in lymphoma staging
52. Diagnostic Techniques Tumor markers:
Tumor markers are molecules occurring in blood or tissue that are associated with cancer and whose measurement or identification is useful in patient diagnosis or clinical management.
Tumor markers are most useful for monitoring response to therapy and detecting early relapse
They are generally products of the cancer cell, although none is unique to cancer cells; they represent aberrant tumor production of a normal element
53. Diagnostic Techniques Tumor markers can be used for one of four purposes:
1- screening a healthy population or a high risk population for the presence of cancer
2- making a diagnosis of cancer or of a specific type of cancer
3- determining the prognosis in a patient
4- monitoring the course in a patient in remission or while receiving surgery, radiation, or chemotherapy.
54. Diagnostic Techniques Carcinoembryonic Antigen “CEA”
The CEA was one of the first oncofetal antigens to be described and exploited clinically.
It is a complex glycoprotein and is associated with the plasma membrane of tumor cells, from which it may be released into the blood.
The primary use of CEA is in monitoring colorectal cancer, especially when the disease has spread and to check recurrence
Other cancers produce elevated levels of this tumor marker, including lymphoma, head and neck cancer and cancers of the breast, lung, pancreas