Adult Neck MassesAdult Neck Masses

Ian Paquette MDIan Paquette MD

DHMC PGY 3-5 Teaching DHMC PGY 3-5 Teaching ConferenceConference

12/20/200612/20/2006

Head and Neck TumorsHead and Neck Tumors

Epithelial TumorsEpithelial Tumors Squamous Cell Carcinoma (>90%)Squamous Cell Carcinoma (>90%) Salivary GlandSalivary Gland AdenocarcinomaAdenocarcinoma ThyroidThyroid MelanomaMelanoma Neuroepithelial tumorsNeuroepithelial tumors Connective Tissue tumorsConnective Tissue tumors LymphomaLymphoma SarcomaSarcoma

Clinical PresentationClinical Presentation**In a smoker > 35 years old, these symptoms In a smoker > 35 years old, these symptoms suggest head and neck cancer until proven suggest head and neck cancer until proven otherwiseotherwise

OdynophagiaOdynophagia DysphagiaDysphagia Weight LossWeight Loss Loose DentitionLoose Dentition Oral FetorOral Fetor TrismusTrismus OtalgiaOtalgia Neck MassNeck Mass Serous Otitis MediaSerous Otitis Media

Nasal ObstructionNasal Obstruction EpistaxisEpistaxis Facial PainFacial Pain Cranial NeuropathiesCranial Neuropathies Secondary InfectionsSecondary Infections AspirationAspiration FistulizationFistulization HemorrhageHemorrhage Airway ObstructionAirway Obstruction

EvaluationEvaluation

Tobacco/AlcoholTobacco/Alcohol – Synergistic effect – Synergistic effect– 15 fold risk of squamous cell carcinoma of the head 15 fold risk of squamous cell carcinoma of the head

and neck compared to the general populationand neck compared to the general populationo Occupational FactorsOccupational Factors - - e.g., nickel workers, wood e.g., nickel workers, wood

workers implicated in paranasal sinus cancer workers implicated in paranasal sinus cancer o Epstein-Barr Virus (EBV)Epstein-Barr Virus (EBV) - - Possible etiological role in Possible etiological role in

nasopharyngeal carcinoma nasopharyngeal carcinoma o Radiation -Radiation - Increased risk of thyroid cancer, parotid Increased risk of thyroid cancer, parotid

neoplasms, malignant degeneration of papillomas and neoplasms, malignant degeneration of papillomas and possibly other upper aerodigestive tract neoplasmspossibly other upper aerodigestive tract neoplasms

EvaluationEvaluation

Physical ExamPhysical Exam– Head and Neck Examination - both Head and Neck Examination - both

inspection and palpation especially oral inspection and palpation especially oral cavity, base of the tongue, and palate cavity, base of the tongue, and palate

– General Physical Examination - distant General Physical Examination - distant metastases, coexisting medical problemsmetastases, coexisting medical problems

EvaluationEvaluationBiopsy - histologic confirmation of the diagnosis is Biopsy - histologic confirmation of the diagnosis is mandatory before pursuing definitive therapymandatory before pursuing definitive therapy

Superficial lesions - punch biopsy - ideal for Superficial lesions - punch biopsy - ideal for readily readily accessible lesions of the skin or mucosa accessible lesions of the skin or mucosa

Deeper lesionsDeeper lesions – Fine needle aspiration with cytology Fine needle aspiration with cytology – Large bore needle Large bore needle – Incisional biopsy - violates capsule and potentially Incisional biopsy - violates capsule and potentially

seeds tumor. seeds tumor. Useful when all diagnostic modalities Useful when all diagnostic modalities have failed to establish a diagnosis and excisional have failed to establish a diagnosis and excisional biopsy of the mass is not technically feasible.biopsy of the mass is not technically feasible.

– Excisional biopsy - removal of a suspected tumor Excisional biopsy - removal of a suspected tumor mass in its entirety. Rarely indicated in squamous mass in its entirety. Rarely indicated in squamous cell carcinomas of the upper aerodigestive tract.cell carcinomas of the upper aerodigestive tract.

Indications for FNAIndications for FNA

• Progressively Progressively enlarging nodesenlarging nodes

• A single asymmetric A single asymmetric nodenode

• A persistent nodal A persistent nodal mass without mass without antecedent active antecedent active signs of infectionsigns of infection

• Actively infectious Actively infectious condition that does condition that does not respond to not respond to conventional conventional antibioticsantibiotics

If no primary is found on examIf no primary is found on exam

Panendoscopy under anesthesiaPanendoscopy under anesthesia– NasopharyngoscopyNasopharyngoscopy– Direct laryngoscopyDirect laryngoscopy– BronchoscopyBronchoscopy– EsophagoscopyEsophagoscopy

– In most cases this identifies the primary In most cases this identifies the primary and will allow appropriate biopsies to be and will allow appropriate biopsies to be takentaken

If there is STILL no evidence of a primary?If there is STILL no evidence of a primary?

Random biopsiesRandom biopsies– NasopharynxNasopharynx– Piriform SinusPiriform Sinus– Base of tongueBase of tongue– Tonsillar fossaTonsillar fossa

StagingStaging

Panendoscopy under general anesthesiaPanendoscopy under general anesthesia– Direct LaryngoscopyDirect Laryngoscopy– EsophagoscopyEsophagoscopy– TracheobronchoscopyTracheobronchoscopy

Important due to a 5-15% incidence of Important due to a 5-15% incidence of synchronous tumorssynchronous tumors

TABLE 42.5 CORRELATION OF PRIMARY SITE AND STAGE OF HEAD AND NECK CANCER WITH SURVIVAL

RATES

Primary site

Survival rate (%)a

Stage I 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

PHARYNX

Nasopharynx 80 60 40 20

Oropharynx 80 60 30 20

Hypopharynx 60 50 30 10

LARYNX

Supraglottic 75 60 50 25

Glottic 95 80 50 30

Subglotticb

aThese numbers represent approximate averages; wide ranges have been reported for all sites and stages.bToo rare for meaningful survival data.     

T1 > 2 cm, T1 > 2 cm, T2 2 – 4 cm T2 2 – 4 cm T3 > 4 cm T4 invasion T3 > 4 cm T4 invasion of antrum of antrum

N0 – no positive nodesN0 – no positive nodesN1 – single node < 3 cmN1 – single node < 3 cmN2a – single node 3 – 6 cmN2a – single node 3 – 6 cmN2b – multiple unilateral nodes < 6 N2b – multiple unilateral nodes < 6 cmcmN2c – multiple bilateral nodes < 6 N2c – multiple bilateral nodes < 6 cmcmN3 -- Nodes > 6 cm N3 -- Nodes > 6 cm

M (distant metastasis)M (distant metastasis)

StagesStagesI T1M0N0I T1M0N0II T2N0M0II T2N0M0III T3N0M0III T3N0M0 T1-3,N1M0T1-3,N1M0IV T1-3,N2-3M0IV T1-3,N2-3M0 T1-3N0-3M1T1-3N0-3M1

Squamous Cell Squamous Cell CarcinomaCarcinoma

TreatmentTreatment

The principles of therapy of head and The principles of therapy of head and neck cancer directed at cure of the neck cancer directed at cure of the disease should try to meet three disease should try to meet three objectives: objectives: – To eradicate the neoplasm completely To eradicate the neoplasm completely – To give the patient the best functional To give the patient the best functional

result by careful planning of the radiation result by careful planning of the radiation fields or appropriate reconstructive fields or appropriate reconstructive techniques for surgical defects techniques for surgical defects

– To leave the patient with as good a To leave the patient with as good a cosmetic result as possiblecosmetic result as possible

TreatmentTreatment

Multimodality treatments Multimodality treatments – Important to discuss at multi-Important to discuss at multi-

specialty tumor boardsspecialty tumor boards Alcohol/Tobacco cessationAlcohol/Tobacco cessation

– Up to 40% risk of recurrenceUp to 40% risk of recurrence– 10-40% risk of developing a 210-40% risk of developing a 2ndnd

primaryprimary

Stage 1 and 2Stage 1 and 2

Radiation or SurgeryRadiation or Surgery– Offer similar resultsOffer similar results– Choice depends on the exact site of Choice depends on the exact site of

the primary and the surgeon’s the primary and the surgeon’s preferencepreference

Stage 3Stage 3

Surgical TreatmentSurgical Treatment– Complete Resection plus Complete Resection plus

reconstructionreconstruction– Often need postoperative radiationOften need postoperative radiation– +/- Adjuvent Chemotherapy on an +/- Adjuvent Chemotherapy on an

individualized basisindividualized basis

Stage 4Stage 4

Chemotherapy Chemotherapy – Cisplatin, 5-FU, etcCisplatin, 5-FU, etc

Palliative SurgeryPalliative Surgery

Follow-UpFollow-Up

Monitor the patient's response to Monitor the patient's response to therapy therapy

To detect recurrence or second primary To detect recurrence or second primary – Every two months in the first year Every two months in the first year – Every three months the second and third Every three months the second and third

year year – At least every six months in the fourth and At least every six months in the fourth and

fifth years fifth years – Yearly thereafter Yearly thereafter

Salivary Gland TumorsSalivary Gland Tumors

Major Salivary GlandsMajor Salivary Glands– Parotid, submandibular, sublingualParotid, submandibular, sublingual

Minor Salivary glandsMinor Salivary glands– found in the submucosa of the found in the submucosa of the

nose, mouth, sinuses, and upper nose, mouth, sinuses, and upper aerodigestive tractaerodigestive tract

Tumors can occur in either major Tumors can occur in either major or minor glandsor minor glands

Salivary Gland TumorsSalivary Gland Tumors

Parotid Gland:Parotid Gland: 80% of salivary tumors 80% of salivary tumors– 80% of these are benign80% of these are benign

Submandibular Gland:Submandibular Gland: 10-15% of tumors 10-15% of tumors– 50% of these are benign50% of these are benign

Sublingual and minor glands:Sublingual and minor glands: 5-10% of 5-10% of tumorstumors– 40% are benign40% are benign

Benign TumorsBenign Tumors

Benign Mixed TumorBenign Mixed Tumor (Pleomorphic adenoma) (Pleomorphic adenoma) - The most common tumor of the - The most common tumor of the parotidparotid gland gland

Warthin's TumorWarthin's Tumor (papillary cystadenoma (papillary cystadenoma lymphomatosum) - Occurs most frequently in lymphomatosum) - Occurs most frequently in the "tail" of the parotid gland of white, the "tail" of the parotid gland of white, middle aged males. middle aged males. Appear "hot" on Tc99 Appear "hot" on Tc99 scan. Bilateral lesions commonly occurscan. Bilateral lesions commonly occur

Malignant TumorsMalignant Tumors

Often asymptomatic, but may show Often asymptomatic, but may show rapid tumor enlargement, pain, rapid tumor enlargement, pain, trismus, or facial nerve palsytrismus, or facial nerve palsy

FNA has 95% sensitivity in salivary FNA has 95% sensitivity in salivary gland neoplasms. Any patient with a gland neoplasms. Any patient with a salivary gland mass should undergo salivary gland mass should undergo FNAFNA– Incisional biopsy is Incisional biopsy is contraindicatedcontraindicated due to due to

tumor seedingtumor seeding

Malignant TumorsMalignant Tumors

Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma - Very lethal even when - Very lethal even when treated early. Although five-year survivals are quite treated early. Although five-year survivals are quite good, 20 year survival is very poor-15% or less good, 20 year survival is very poor-15% or less depending on site of origin. depending on site of origin. Most patients die of Most patients die of pulmonary metastasespulmonary metastases. This tumor also has a . This tumor also has a proclivity for perineural spread. proclivity for perineural spread.

Mucoepidermoid CarcinomaMucoepidermoid Carcinoma - Graded into high grade - Graded into high grade (very malignant and lethal) to low grade (very curable (very malignant and lethal) to low grade (very curable with surgery alone). The most common parotid tumor with surgery alone). The most common parotid tumor seen in seen in childhoodchildhood. .

Malignant TumorsMalignant Tumors

Acinic Cell CarcinomaAcinic Cell Carcinoma - Low grade - Low grade malignancy malignancy

Squamous Cell CarcinomaSquamous Cell Carcinoma - Very aggressive - Very aggressive tumor. tumor. Must rule out metastasis from a skin Must rule out metastasis from a skin lesion to parotid lymph nodeslesion to parotid lymph nodes. Primary . Primary parotid lesions tend to metastasize to parotid lesions tend to metastasize to

cervical lymph nodes.cervical lymph nodes.

Treatment of parotid Treatment of parotid tumorstumors

Superficial parotidectomy for Superficial parotidectomy for benign tumorsbenign tumors

Treatment of parotid Treatment of parotid tumorstumors

Malignant tumors often warrant Malignant tumors often warrant total parotidectomytotal parotidectomy

Facial nerve is sacraficed only for Facial nerve is sacraficed only for direct invasion or pre-existing direct invasion or pre-existing facial nerve paralysisfacial nerve paralysis

Squamous cell or high grade Squamous cell or high grade mucoepidermoid – may require a mucoepidermoid – may require a neck dissectionneck dissection

Treatment of parotid Treatment of parotid tumorstumors

RadiationRadiation– High grade tumorsHigh grade tumors– Close MarginsClose Margins– Recurrent diseaseRecurrent disease– Positive nodesPositive nodes– Unresectable diseaseUnresectable disease

No effective chemotherapyNo effective chemotherapy

Submandibular and Sublingual Submandibular and Sublingual glandsglands

o Complete excisions of the gland and tumor. Complete excisions of the gland and tumor. o If a malignancy is discovered, then a neck If a malignancy is discovered, then a neck

dissection and perhaps excision of the floor dissection and perhaps excision of the floor of mouth may be indicated depending on the of mouth may be indicated depending on the

tumor type.tumor type.

Minor Salivary GlandsMinor Salivary Glands

The operation depends on the location of the The operation depends on the location of the involved gland, involved gland, but complete excision with a but complete excision with a margin of normal tissue is essentialmargin of normal tissue is essential. .

In the case of In the case of adenoidcystic carcinomasadenoidcystic carcinomas, , surrounding nerves must be sampled for surrounding nerves must be sampled for

possible invasion and excised if involved.possible invasion and excised if involved.

THE ENDTHE END