Download Adult Neck Masses - Dartmouth

Adult Neck Masses
Ian Paquette MD
DHMC PGY 3-5 Teaching Conference
12/20/2006
Head and Neck Tumors
Epithelial Tumors
 Squamous Cell Carcinoma (>90%)
 Salivary Gland
 Adenocarcinoma
 Thyroid
 Melanoma
 Neuroepithelial tumors
 Connective Tissue tumors
 Lymphoma
 Sarcoma
Clinical Presentation
*In a smoker > 35 years old, these symptoms suggest
head and neck cancer until proven otherwise
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Odynophagia
Dysphagia
Weight Loss
Loose Dentition
Oral Fetor
Trismus
Otalgia
Neck Mass
Serous Otitis Media
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Nasal Obstruction
Epistaxis
Facial Pain
Cranial Neuropathies
Secondary Infections
Aspiration
Fistulization
Hemorrhage
Airway Obstruction
Evaluation
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o
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Tobacco/Alcohol – Synergistic effect
– 15 fold risk of squamous cell carcinoma of the head and
neck compared to the general population
Occupational Factors - e.g., nickel workers, wood workers
implicated in paranasal sinus cancer
Epstein-Barr Virus (EBV) - Possible etiological role in
nasopharyngeal carcinoma
Radiation - Increased risk of thyroid cancer, parotid
neoplasms, malignant degeneration of papillomas and possibly
other upper aerodigestive tract neoplasms
Evaluation
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Physical Exam
– Head and Neck Examination - both inspection
and palpation especially oral cavity, base of the
tongue, and palate
– General Physical Examination - distant
metastases, coexisting medical problems
Evaluation
Biopsy - histologic confirmation of the diagnosis is
mandatory before pursuing definitive therapy
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Superficial lesions - punch biopsy - ideal for readily accessible
lesions of the skin or mucosa
Deeper lesions
– Fine needle aspiration with cytology
– Large bore needle
– Incisional biopsy - violates capsule and potentially seeds
tumor. Useful when all diagnostic modalities have failed to
establish a diagnosis and excisional biopsy of the mass is
not technically feasible.
– Excisional biopsy - removal of a suspected tumor mass in
its entirety. Rarely indicated in squamous cell carcinomas
of the upper aerodigestive tract.
Indications for FNA
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Progressively enlarging
nodes
A single asymmetric
node
A persistent nodal mass
without antecedent
active signs of infection
Actively infectious
condition that does not
respond to conventional
antibiotics
If no primary is found on exam
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Panendoscopy under anesthesia
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Nasopharyngoscopy
Direct laryngoscopy
Bronchoscopy
Esophagoscopy
– In most cases this identifies the primary and will
allow appropriate biopsies to be taken
If there is STILL no evidence of a primary?
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Random biopsies
– Nasopharynx
– Piriform Sinus
– Base of tongue
– Tonsillar fossa
Staging
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Panendoscopy under general anesthesia
– Direct Laryngoscopy
– Esophagoscopy
– Tracheobronchoscopy
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Important due to a 5-15% incidence of
synchronous tumors
Squamous Cell Carcinoma
TABLE 42.5 CORRELATION OF
PRIMARY SITE AND STAGE OF HEAD
AND NECK CANCER WITH SURVIVAL
RATES
Survival rate (%)
Primary site
Stage I
a
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
Nasopharynx
80
60
40
20
Oropharynx
80
60
30
20
Hypopharynx
60
50
30
10
Supraglottic
75
60
50
25
Glottic
95
80
50
30
PHARYNX
T1 > 2 cm,
T3 > 4 cm
of antrum
T2 2 – 4 cm
T4 invasion
N0 – no positive nodes
N1 – single node < 3 cm
N2a – single node 3 – 6 cm
N2b – multiple unilateral nodes < 6 cm
N2c – multiple bilateral nodes < 6 cm
N3 -- Nodes > 6 cm
M (distant metastasis)
LARYNX
Subglottic
b
These numbers represent approximate averages; wide ranges have been reported for all sites and
stages.
Too rare for meaningful survival data.
a
b
Stages
I
T1M0N0
II T2N0M0
III T3N0M0
T1-3,N1M0
IV T1-3,N2-3M0
T1-3N0-3M1
Treatment
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The principles of therapy of head and neck
cancer directed at cure of the disease
should try to meet three objectives:
– To eradicate the neoplasm completely
– To give the patient the best functional result by
careful planning of the radiation fields or
appropriate reconstructive techniques for
surgical defects
– To leave the patient with as good a cosmetic
result as possible
Treatment
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Multimodality treatments
– Important to discuss at multi-specialty
tumor boards
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Alcohol/Tobacco cessation
– Up to 40% risk of recurrence
– 10-40% risk of developing a 2nd primary
Stage 1 and 2
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Radiation or Surgery
– Offer similar results
– Choice depends on the exact site of the
primary and the surgeon’s preference
Stage 3
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Surgical Treatment
– Complete Resection plus reconstruction
– Often need postoperative radiation
– +/- Adjuvent Chemotherapy on an
individualized basis
Stage 4
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Chemotherapy
– Cisplatin, 5-FU, etc
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Palliative Surgery
Follow-Up
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Monitor the patient's response to therapy
To detect recurrence or second primary
– Every two months in the first year
– Every three months the second and third year
– At least every six months in the fourth and fifth
years
– Yearly thereafter
Salivary Gland Tumors
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Major Salivary Glands
– Parotid, submandibular, sublingual
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Minor Salivary glands
– found in the submucosa of the nose,
mouth, sinuses, and upper aerodigestive
tract
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Tumors can occur in either major or
minor glands
Salivary Gland Tumors
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Parotid Gland: 80% of salivary tumors
– 80% of these are benign
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Submandibular Gland: 10-15% of tumors
– 50% of these are benign
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Sublingual and minor glands: 5-10% of tumors
– 40% are benign
Benign Tumors
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Benign Mixed Tumor (Pleomorphic adenoma) - The
most common tumor of the parotid gland
Warthin's Tumor (papillary cystadenoma
lymphomatosum) - Occurs most frequently in the
"tail" of the parotid gland of white, middle aged
males. Appear "hot" on Tc99 scan. Bilateral lesions
commonly occur
Malignant Tumors
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Often asymptomatic, but may show rapid
tumor enlargement, pain, trismus, or facial
nerve palsy
FNA has 95% sensitivity in salivary gland
neoplasms. Any patient with a salivary gland
mass should undergo FNA
– Incisional biopsy is contraindicated due to tumor
seeding
Malignant Tumors
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Adenoid Cystic Carcinoma - Very lethal even when treated
early. Although five-year survivals are quite good, 20 year
survival is very poor-15% or less depending on site of origin.
Most patients die of pulmonary metastases. This tumor also
has a proclivity for perineural spread.
Mucoepidermoid Carcinoma - Graded into high grade (very
malignant and lethal) to low grade (very curable with surgery
alone). The most common parotid tumor seen in childhood.
Malignant Tumors
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Acinic Cell Carcinoma - Low grade malignancy
Squamous Cell Carcinoma - Very aggressive tumor.
Must rule out metastasis from a skin lesion to
parotid lymph nodes. Primary parotid lesions tend
to metastasize to cervical lymph nodes.
Treatment of parotid tumors
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Superficial parotidectomy for benign
tumors
Treatment of parotid tumors
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Malignant tumors often warrant total
parotidectomy
Facial nerve is sacraficed only for
direct invasion or pre-existing facial
nerve paralysis
Squamous cell or high grade
mucoepidermoid – may require a neck
dissection
Treatment of parotid tumors
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Radiation
– High grade tumors
– Close Margins
– Recurrent disease
– Positive nodes
– Unresectable disease
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No effective chemotherapy
Submandibular and Sublingual glands
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Complete excisions of the gland and tumor.
If a malignancy is discovered, then a neck
dissection and perhaps excision of the floor of
mouth may be indicated depending on the tumor
type.
Minor Salivary Glands
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The operation depends on the location of the
involved gland, but complete excision with a margin
of normal tissue is essential.
In the case of adenoidcystic carcinomas,
surrounding nerves must be sampled for possible
invasion and excised if involved.
THE END