Epidemiology and Pathophysiology

Report
Head and Neck Cancer
Epidemiology, Anatomy, Presentation,
Surgical Options
Charles J. Zeller, IV, DO
Community ENT Care
Otolaryngology Associates
HNC: The Statistics
Cancer Cases and Deaths of the Oral Cavity & Pharynx by
Sex, United States, 2012
Men
Women
 New Cases=28,540
 New Cases=11,710
 8th leading cause of
cancer in men
 New Deaths=2,410
 Lifetime probability
is 1 in 69
 New Deaths=5,440
American Cancer Society. Cancer Facts & Figures 2012.
U.S. Incidence Rates for
HNC
 In 2012, >40,000 new cases
 Incidence more than
twice as high in men as
in women
 From 2004 to 2008,
incidence rates declined
1.0% per year in
and were stable
by
women
in men
 Incidence is increasing for oropharynx cancers
associated with human papillomavirus (HPV)
American Cancer Society. Cancer Facts & Figures 2012.
National Cancer Institute. A Snapshot of Head and Neck Cancer. October 2011.
U.S. Mortality Rates for
HNC
 >7,850 deaths from oral
cavity and pharynx
cancer in 2012
 Death rates have been
decreasing over the past 3
decades
 From 2004 to 2008, rates
decreased by 1.2% per year
in men and by 2.2% per
year in women
American Cancer Society. Cancer Facts & Figures 2012.
National Cancer Institute. A Snapshot of Head and Neck Cancer. October 2011.
U.S. Survival Rates for
HNC
 For all stages of HNC combined, about
 84% survive 1 year after diagnosis
 61% survive 5 years after diagnosis, and
 50% survive 10 years after diagnosis
Five-year Relative Survival Rates by Stage at Diagnosis, 2001-2007*
Oral
cavity
&
pharynx
All
Stages
Local
Regiona
l
Distant
61%
82%
56%
34%
*Rates are adjusted for normal life expectancy and are based on cases
diagnosed in the SEER 17 areas from 2001-2007, followed through 2008.
American Cancer Society. Cancer Facts & Figures 2012.
Relative Survival Rate (%) by
Primary HNC Site, 1988-2001
Piccirillo JF, et al. National Cancer Institute. SEER Survival Monograph. Chapter 2
HNC Risk Factors
 Known risk factors:
 All forms of smoked and
smokeless tobacco
products
 Excessive consumption of
alcohol
 30-fold increased risk for
individuals who both
smoke and drink heavily!
 HPV infection associated
with cancers of
 Tonsil
 Base of tongue
 Other sites within the
oropharynx
 Believed to be transmitted
through sexual contact
American Cancer Society. Cancer Facts & Figures 2012.
Smoking-Associated HNC
American Cancer Society. Cancer Statistics 2012.
Tobacco Use and Related
Cancers on the Decline
American Cancer Society. Cancer Statistics 2012.
Diagnosis and Staging
Head and Neck Cancer (HNC)
Oral cavity
Nasal antrum
Lip
Buccal mucosa
Alveolar ridge and
retromolar trigone
Floor of mouth
Hard palate
Oral tongue
(anterior two thirds)
Larynx
Supraglottis
False cords
Arytenoids
Epiglottis
Arytenoepiglottic fold
Glottis
Subglottis
Nasopharynx
Oropharynx
Base of tongue
Soft palate
Tonsillar pillar
and fossa
Hypopharynx
Esophagus
Pharynx
Anatomy
Cervical Lymph Nodes
Anatomy: Nasopharynx
 Eustachian tube
 Torus Tubaris
 Fossa of Rosenmuller
Anatomy: Oro/Hypopharynx
 From the uvula to hyoid bone
 Palatine tonsils, tonsillar pillars
 Base of tongue
 Epiglottis and vallecula
Anatomy: Laryngopharynx
 From the epiglottis to the inferior cricoid cartilage
 Vocal cords, piriform sinuses, arytenoid cartilage and
aryepiglottic folds
Head and Neck Cancer
Signs and Symptoms

Persistent hoarseness

Palpable mass in neck
 Branchial cleft cysts rarely present later than young adulthood
 Neck mass in persons >40 yrs of age should be considered a malignancy until proven
otherwise

Ear infection or pain

Altered oral sensations or persistent sore throat

Lesions in mouth
 Erythroplasia (early red lesions)
 Leukoplakia (white lesions)
 Persistent mass or ulcer (usually oral cavity)

Difficulties in chewing, swallowing, or moving the tongue or jaws are often late symptoms
Chin D, et al. Expert Rev Anticancer Ther. 2006;6:1111-1118.
NCCN Clinical Practice Guidelines. Head and Neck Cancers. V2. 2011.
American Cancer Society. Oral Cavity and Oropharyngeal Cancer, Laryngeal and Hypopharyngeal Cancer.
Head and Neck Cancer
Typical Presentation
 Symptoms include:









Persisting hoarseness
Dysphagia
Hemoptysis
Throat pain
Ear pain
Airway compromise
Unexplained aspiration
Neck mass
Weight loss
Larynx Cancer
Presentation
 Hoarseness is the most common symptom
 Sore throat or cough that does not go away
 Patients presenting with new onset or worsening
hoarseness should undergo indirect mirror exam
and/or flexible laryngoscopy
 Videostroboscopy may be recommended
 Good neck exam, look for cervical adenopathy
 Palpate base of tongue for masses
HNC Evaluation

Inspection and palpation

Biopsy of any suspicious mucosal surface

Imaging
 CT, MRI
 Barium swallowing study
 PET/CT of value in identifying neck disease and unknown primaries
 CT of chest if there are neck nodes and no PET/CT as lung metastases
common first distant site
 New cystic lesion in the neck unlikely to be recent onset branchial cleft
cyst in an adult

FNA of lymph node

Examination under anesthesia
 Full evaluation of the areas at risk
NCCN Clinical Practice Guidelines. Head and Neck Cancers. V2. 2011.
American Cancer Society. Oral Cavity and Oropharyngeal Cancer, Laryngeal and Hypopharyngeal Cancer.
Premalignant changes
Presentation: Nasopharynx
Oral Cavity Cancer
Presentation
Tongue cancer
Presentation: Oropharynx
 Globus sensation
 Difficultly swallowing
 Slurred speech
 Pain in throat or ear
 Neck mass
Presentation: Larynx
 Hoarse voice
 Stridor
 Cough, hx of GERD
 Trouble swallowing
 For glottic tumors
 T1-2 5% LN involvement
 T3-4 20% LN involvement
Histopathology
Considerations for HNC
 Premalignant lesions




Leukoplakia
Erythroplakia
Squamous dysplasia
Lichen planus
 Carcinoma in-situ (CIS) and early invasive
squamous cell carcinoma (SCC)
 Atypical squamous cells exhibiting nuclear atypia
 Increased nuclear-to-cytoplasmic ratio
 Varying degrees of keratinization
Park BJ, et al. Cancer Biomark. 2010;9:325-339.
Histology
 90% of H&N cancers are squamous cell carcinomas
arising from the mucosal surfaces
 Salivary gland tumors are typically adenocarcinomas
How To Treat Head and
Neck Cancer
 Find it, usually late
-over 80% of tumors are late stage
 Surgery (cut it out)
 Radiation (burn it)
 Chemotherapy (selective poisoning)
 Combine the above
Head and Neck Cancer
Management
 Multimodality therapy for all but very early stages:
surgery, radiation with adjuvant chemotherapy
 Significant morbidity due to therapy is possible:
cosmesis, decreased saliva, swallowing dysfunction,
social dysfunction
 Novel molecular directed therapies incorporated into
next generation trials
Oral Cavity/Oropharynx Surgical
Approaches
 Transoral
 Visor
 Lip Split with or without mandibulotomy
 Lip Split with Mandibulectomy
Oral Cavity/Oropharynx
Surgical Approaches
 Transoral and Visor Approaches
 Cosmetic but may limit exposure
 Lip Splitting
 Modest cosmetic disadvantage with excellent
posterior exposure for mandibulotomy
 Paramedian or midline mandibulotomy
 Avoidance of alveolar nerve
Primary Surgery + Radiation Indicated
for Advanced Oral Cavity Cancer
 Low local control for primary radiotherapy for
advanced oral cavity (30-40%) and poor survival
(25%)
 Increased local control with surgery +
radiotherapy (60%) and improved survival (55%)

Zelefsky et al, Head Neck. 1990 Nov-Dec;12(6):470-5
 Local control significantly improved for locally
advanced T3, T4 oral cancers using surgery +
postoperative radiotherapy vs. primary RT

Fein et al. Head Neck. 1994 Jul-Aug;16(4):358-65
Surgical Resection
Advances
Reconstruction
 Free Tissue Transfer
 Mandibular reconstruction (fibula, scapula, etc.)
 Soft tissue/tongue (radial forearm, rectus
abdominus, lateral thigh, etc.)
 Resection is rarely limited by size or extent of
tumor
Surgical Management Options-Role for Minimally Invasive
Approaches?
 Transoral laser microsurgery or robotic assisted
surgery may be utilized in select patient
populations
 Selected tumors of oropharynx and larynx
 HPV demographic
 Quicker recovery, faster return to swallowing,
decreased rates of tracheostomy and gastrostomy
tube dependence.
 Disease free/survival outcomes appear equal to that
offered by primary chemoradiation
Transoral Robotic Assisted
Surgery--TORS
 Concept of De-Intensification of Therapy through TORS
 Currently only in clinical trial setting
 Await the data??
 15-30 % of patients avoid radiation
 Significantly lower doses and focused treatment fields
when used.
 40-70 % patients avoid chemotherapy
 Reduced rate of PEG dependency
 Survival statistics equal to or surpassing other modalities
Surgical Management of
Laryngeal Malignancy
 Premalignant lesions or Carcinoma in situ can be
managed by surgical excision/stripping of the
entire lesion
 CO2 laser can be utilized
 Early stage (T1 and T2) can be treated with
radiotherapy or surgery alone, both with 85-95%
cure rate
 Surgery has shorter treatment period but may have
poorer voice outcomes
Surgical Management of
Laryngeal Malignancy
 Advanced stage lesions often receive surgery
followed by adjuvant radiation therapy
 Most T3 and T4 lesions require a total
laryngectomy/pharyngectomy
 Reconstruction of aerodigestive tract with locoregional flap or free tissue transfer
 Some small T3 and lesser sized lesions can be
managed by partial laryngectomy
Surgical Management of
Laryngeal Malignancy
 Modified or radical neck dissection is indicated in the
presence of known nodal disease or locally advanced
tumors
 N0 necks can have a selective neck dissection sparing
SCM, IJV, and CN XI
 Supraglottic and subglottic tumors have higher rate of
occult cervical metastasis due to lymphatic drainage
patterns
 Extension to subglottic space associated with a higher
incidence of stomal recurrence following total
laryngectomy
Voice Rehabilitation After
Laryngectomy
 Tracheoesophageal voice prosthesis
 Electrolarynx
 Pure esophageal speech
 Role of speech and language
pathologist for rehabilitation
Case Presentation
 73 Y edentulous farmer with a right gingival
lesion, otherwise asymptomatic
 120 PY smoking history, currently smoking
 Past Medical History: diabetes, coronary artery
disease, myocardial infarction x 2, carotid
endarterectomy, peripheral vascular disease,
and hypertension, renal insufficiency
 Exam shows a right lower gingival mass, 2.5 cm
squamous cell carcinoma
Case Presentation
 CT demonstrates R mandibular invasion
Case Presentation
 PET/CT demonstrates no evidence of metastasis
 MR angiography demonstrates severe peripheral
vascular disease in bilateral lower extremities
Case Presentation
Therapy
 Resection from paramedian to angle of mandible to
encompass alveolar nerve
Case Presentation
Treatment Options
 T4N0M0 squamous cell carcinoma of the right alveolus
 Right mandibulectomy (via visor flap), right neck
dissection, fibula free flap, tracheotomy, postoperative
radiation and chemotherapy
 Transoral mandiblectomy, postoperative radiation to
primary site and ipsilateral neck
Case Presentation
Outcome
 Oral alimentation at 5 days postop
 External beam radiation to primary and ipsilateral neck
onset 3 weeks post surgery
 Acceptable cosmetic appearance
 NED at 30 mo, died shortly after from MI
Questions?
Contact:
Charles J. Zeller, IV, DO
Community ENT Care
Otolaryngology Associates
317-844-7059
[email protected]
Thank You!

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