Download classification of cytotoxic agents

HEAD & NECK CANCER
Clinical Division of Oncology
Department of Medicine I
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Worldwide incidence and
mortality (estimated)
Cases (thousands)
160
120
80
40
0
141
66
Mouth
77
40
24
Nasopharynx
Incidence
Clinical Division of Oncology
Department of Medicine I
50
Other Pharynx
Cases (thousands)
Females (thousands)
Males (thousands)
160
120
80
40
0
70
34
Mouth
Mortality
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
18
Nasopharynx
Incidence
17
11
12
Other Pharynx
Mortality
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Incidence of cancer of the lip, oral cavity,
or pharynx in males by world region
Western
Europe
21.78
Eastern
Europe
13.69
Japan
*Incidence per 100,000 population.
Clinical Division of Oncology
Department of Medicine I
Parkin DM, et al. CA Cancer J Clin 1999;49:33-64.
4.94
Australia/
New Zealand
19.16
South Central
Asia
20.50
North
Africa
8.40
South
Africa
20.23
Temperate
South America
11.35
North
America
11.69
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Risk factors
• Tobacco
• Alcohol
• Male gender
• Poor orodental care
• Genetic susceptibility
• Occupational exposure
• Malnutrition
• Mechanical irritation
• Chronic viral infection
Clinical Division of Oncology
Department of Medicine I
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998;165.
Shaha AR, et al. American Cancer Society Textbook of Clinical
Oncology. 3rd ed. 2001;297-329.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Nasopharyngeal cancer
and Epstein-Barr virus
• Endemic in regions of Northern Africa
and Asia
• Etiology distinct from other head and
neck cancers
• Epstein-Barr viral proteins detectable
in the majority of nasopharyngeal tumors
• Associated with frequent consumption
of salted fish or nitrosamines
Clinical Division of Oncology
Department of Medicine I
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998;165-166.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Prevention
• Avoidance of tobacco and
alcohol
• Routine medical examination
• Participation in
chemoprevention trials
Clinical Division of Oncology
Department of Medicine I
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998;165.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Early detection in patients
at risk
• Annual physical examination
• Special attention to upper aerodigestive
tract and neck with digital examination
of oral cavity
• Referral for evaluation of unexplained
symptoms
• Biopsy/follow-up for leukoplakia
Clinical Division of Oncology
Department of Medicine I
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998;165.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Screening of high-risk
patients
Not generally successful due to:
• Low level of participation of high-risk
patients in screening programs
• Prolonged subclinical disease state
• Constraints on time and need for
education in primary-care setting
Clinical Division of Oncology
Department of Medicine I
Schantz SP, et al. Cancer: Principles & Practice of Oncology.
6th ed. 2001;797-860.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Host susceptibility
Evaluation of identifiable risk factors may
improve screening:
• Carcinogen-metabolizing enzymes
• Characteristics of race/gender
• Human leukocyte antigen (HLA) phenotypes
• Cancer family syndromes
• DNA repair deficiencies
Clinical Division of Oncology
Department of Medicine I
Schantz SP, et al. Cancer: Principles & Practice of Oncology.
5th ed. 1997;744-745.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Anatomy
Clinical Division of Oncology
Department of Medicine I
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Lymph node regions
Preauricular
Postauricular
Facial
Upper Post. Cervical
(Spinal Accessory Chain)
Intraauricular
Submandibular
Submental
Superf. Occipital
Middle Post. Cervical
(Spinal Accessory Chain)
Lower Post. Cervical
Subdigastric Node
Upper Jugular
(Spinal Accessory Chain)
Supraclavicular
(Trans. Cervical Chain)
Mid-Jugular
Lower Jugular
Clinical Division of Oncology
Department of Medicine I
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Sites
I
II
III
V
IV
Clinical Division of Oncology
Department of Medicine I
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Malignant tumors
Squamous cell carcinoma
Most common primary
cancer (90%)
Differentiation
(well-moderate-poor)
based on
keratinization
Lymphomas
Non-Hodgkin lymphomas
Hodgkin lymphoma
Metastatic cancers
Lung
Gastrointestinal tract
(Virchow’s node)
Other carcinomas
Adenocarcinoma
Breast
Mucoepidermoid
Lymphoepithelioma
Clinical Division of Oncology
Department of Medicine I
Calcaterra A, Juillard GJF. Cancer Treatment. 4th ed. 1995;712.
Schantz SP, et al. Cancer: Principles & Practice of Oncology. 6th
ed. 2001;797-860.
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998;165.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Staging (Lip, oral cavity,
oropharynx, and hypopharynx)
Stage
T
N
M
0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
III
T3
T1
T2
T3
N0
N1
N1
N1
M0
M0
M0
M0
IVA
T4
Any T
Any T
Any T
Any T
N0, N1
N2, N3
Any N
N3
Any N
M0
M0
M1
M0
M1
IVB
IVC
Clinical Division of Oncology
Department of Medicine I
AJCC® Cancer Staging Manual, 5th ed. (1997)
published by Lippincott-Raven Publishers, Philadelphia,
Pennsylvania.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Tumor staging
(Lip and oral cavity)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor 2 cm or less in greatest diameter
T2
Tumor more than 2 cm but not more than 4 cm in greatest diameter
T3
Tumor more than 4 cm in greatest diameter
T4 (lip)
Tumor invades adjacent structures (e.g., through cortical bone, inferior
alveolar nerve, floor of mouth, skin of face)
T4 (oral cavity)
Tumor invades adjacent structures (e.g., through cortical bone, into deep [extrinsic]
muscle of tongue, maxillary sinus, skin. Superficial erosion alone of bone/tooth
socket by gingival primary is not sufficient to classify as T4)
Clinical Division of Oncology
Department of Medicine I
AJCC® Cancer Staging Manual, 5th ed. (1997)
published by Lippincott-Raven Publishers, Philadelphia,
Pennsylvania.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Nodal staging
(Lip and oral cavity)
NX
Regional lymph nodes cannot be assessed
N0
No regional lymph node metastasis
N1
Metastasis in a single ipsilateral lymph node, not more than 3 cm in greatest diameter
N2a
Metastasis in a single ipsilateral lymph node more than 3 cm but not more than
6 cm in greatest diameter
N2
Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than
6 cm in greatest diameter; or in multiple ipsilateral lymph nodes, none more than 6 cm in
greatest diameter; or in bilateral or contralateral lymph nodes, none more than 6 cm in
greatest diameter
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest diameter
N2c
Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest
diameter
N3
Metastasis in a lymph node more than 6 cm in greatest diameter
Clinical Division of Oncology
Department of Medicine I
AJCC® Cancer Staging Manual, 5th ed. (1997)
published by Lippincott-Raven Publishers, Philadelphia,
Pennsylvania.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Staging and survival
Stage
AJCC Stage*
5-Year Survival
I
T1
75-90%
II
T2
40-70%
III
T3
20-50%
IV
T4
<10-30%
*Approximate corresponding stage based on extent of primary disease (T).
Clinical Division of Oncology
Department of Medicine I
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Distribution by stage
of newly diagnosed disease
10%
Distant Disease
Localized Disease
Regional Metastases
50%
40%
Clinical Division of Oncology
Department of Medicine I
Ries LG, et al. SEER Cancer Statistics Review, 1973-1991:
Tables and Graphs, National Cancer Institute.
NIH Pub. No. 94-2789. Bethesda, MD, 1994.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Prognostic factors
Factor
Implications
Nodal involvement, N-stage
Most important factor: better prognosis in N0 than
in N1-disease
Extracapsular spread
Increases tendency for recurrence and
distant metastases
Tumor size
Smaller, less invasive tumor predicts
better outcomes
Hypopharyngeal involvement
Commonly advanced disease with poor prognosis
Laryngeal involvement
Potential for organ preservation
Nasopharyngeal involvement
Generally chemosensitive tumors, but with tendency
for distant metastases and late relapse
Clinical Division of Oncology
Department of Medicine I
Stupp R, Vokes EE. Current Cancer Therapeutics. 3rd ed.
1998.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Premalignancy
• Leukoplakia
• Erythroplakia
• Hyperplasia
• Dysplasia
Clinical Division of Oncology
Department of Medicine I
Schantz SP, et al. Cancer: Principles & Practice of Oncology.
6th ed. 2001;797-860.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Physical evaluation
• Inspection of mucosa
• Bimanual examination of oral cavity
• Palpation of neck
• Biopsy of leukoplakia, erythroplakia,
erythroleukoplakia
• Indirect laryngoscopy
• Endoscopic examination
– Direct laryngoscopy
– Esophagoscopy
– Bronchoscopy
Clinical Division of Oncology
Department of Medicine I
Vokes EE, et al. N Engl J Med. 1993;328:186.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Radiographic evaluation
Radiographic Technique
Advantages
Computed Tomography (CT) Scan
Fast, less prone to motion artifacts
Currently better than MR for evaluating
metastatic adenopathy
Ideal for non-MR candidates
Increased sensitivity - osseous destruction
Cost
No iodinated contrast media
No radiation-exposure
Muliplanar capability
No dental amalgam artifact
Superior soft tissue contrast
May be better than CT for staging of
primary tumor
Magnetic Resonance Imaging (MRI)
Clinical Division of Oncology
Department of Medicine I
Madison MT, et al. Radiol Clin North Am. 1994;32:163.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Pretreatment considerations
Co-morbidity (chronic diseases)
Pulmonary
Cardiovascular
Digestive
Malnutrition
Resulting from poor dietary habits or symptoms
Severe in over 25% of patients
Oral health
Periodontal disease, infections, and caries common
Dental rehabilitation indicated prior to radiotherapy
Clinical Division of Oncology
Department of Medicine I
Schantz SP, et al. Cancer: Principles & Practice of Oncology.
6th ed. 2001;797-860.
Medical University of
Vienna, Austria
HEAD & NECK CANCER
Second primary
malignancies
• Incidence of synchronous second
primary tumors is 15%
• Risk of developing second tumors is
4% per year on follow-up
• Tumors common in tobacco-exposed
tissues – i.e. lung, esophagus,
aerodigestive tract
• Close observation and cancer
surveillance important
Clinical Division of Oncology
Department of Medicine I
Shaha AR, et al. American Cancer Society Textbook of Clinical
Oncology. 3rd ed. 2001;297-329.
Schantz SP, et al. Cancer: Principles & Practice of Oncology.
6th ed. 2001;797-860.
Medical University of
Vienna, Austria