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Epidemiology, Anatomy, Presentation, Surgical Options Head and Neck Cancer Charles J. Zeller, IV, DO Community ENT Care Otolaryngology Associates.

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Presentation on theme: "Epidemiology, Anatomy, Presentation, Surgical Options Head and Neck Cancer Charles J. Zeller, IV, DO Community ENT Care Otolaryngology Associates."— Presentation transcript:

1 Epidemiology, Anatomy, Presentation, Surgical Options Head and Neck Cancer Charles J. Zeller, IV, DO Community ENT Care Otolaryngology Associates

2 HNC: The Statistics Men New Cases=28,540 New Cases=28,540 8 th leading cause of cancer in men 8 th leading cause of cancer in men Lifetime probability is 1 in 69 Lifetime probability is 1 in 69 New Deaths=5,440 New Deaths=5,440 Women New Cases=11,710 New Deaths=2,410 Cancer Cases and Deaths of the Oral Cavity & Pharynx by Sex, United States, 2012 American Cancer Society. Cancer Facts & Figures 2012.

3 U.S. Incidence Rates for HNC In 2012, >40,000 new cases In 2012, >40,000 new cases Incidence more than twice as high in men as in women Incidence more than twice as high in men as in women From 2004 to 2008, incidence rates declined by 1.0% per year in women and were stable in men From 2004 to 2008, incidence rates declined by 1.0% per year in women and were stable in men Incidence is increasing for oropharynx cancers associated with human papillomavirus (HPV) 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.

4 U.S. Mortality Rates for HNC >7,850 deaths from oral cavity and pharynx cancer in 2012 >7,850 deaths from oral cavity and pharynx cancer in 2012 Death rates have been decreasing over the past 3 decades 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 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.

5 U.S. Survival Rates for HNC For all stages of HNC combined, about For all stages of HNC combined, about 84% survive 1 year after diagnosis 84% survive 1 year after diagnosis 61% survive 5 years after diagnosis, and 61% survive 5 years after diagnosis, and 50% survive 10 years after diagnosis 50% survive 10 years after diagnosis American Cancer Society. Cancer Facts & Figures 2012. Five-year Relative Survival Rates by Stage at Diagnosis, 2001-2007* Oral cavity & pharynx All Stages LocalRegiona 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.

6 Piccirillo JF, et al. National Cancer Institute. SEER Survival Monograph. Chapter 2 Relative Survival Rate (%) by Primary HNC Site, 1988-2001

7 HNC Risk Factors Known risk factors: Known risk factors: All forms of smoked and smokeless tobacco products All forms of smoked and smokeless tobacco products Excessive consumption of alcohol Excessive consumption of alcohol 30-fold increased risk for individuals who both smoke and drink heavily! 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.

8 Smoking-Associated HNC American Cancer Society. Cancer Statistics 2012.

9 Tobacco Use and Related Cancers on the Decline American Cancer Society. Cancer Statistics 2012.

10 Diagnosis and Staging

11 Head and Neck Cancer (HNC) Nasal antrum Nasopharynx Oropharynx Base of tongue Soft palate Tonsillar pillar and fossa Hypopharynx Esophagus Supraglottis False cords Arytenoids Epiglottis Arytenoepiglottic fold Glottis Subglottis Lip Buccal mucosa Alveolar ridge and retromolar trigone Floor of mouth Hard palate Oral tongue (anterior two thirds) Oral cavity Larynx Pharynx

12 Anatomy

13 Cervical Lymph Nodes

14 Anatomy: Nasopharynx Eustachian tube Eustachian tube Torus Tubaris Torus Tubaris Fossa of Rosenmuller Fossa of Rosenmuller

15 Anatomy: Oro/Hypopharynx From the uvula to hyoid bone From the uvula to hyoid bone Palatine tonsils, tonsillar pillars Palatine tonsils, tonsillar pillars Base of tongue Base of tongue Epiglottis and vallecula Epiglottis and vallecula

16 Anatomy: Laryngopharynx From the epiglottis to the inferior cricoid cartilage From the epiglottis to the inferior cricoid cartilage Vocal cords, piriform sinuses, arytenoid cartilage and aryepiglottic folds Vocal cords, piriform sinuses, arytenoid cartilage and aryepiglottic folds

17 Head and Neck Cancer Signs and Symptoms Persistent hoarseness Persistent hoarseness Palpable mass in neck Palpable mass in neck Branchial cleft cysts rarely present later than young adulthood 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 Neck mass in persons >40 yrs of age should be considered a malignancy until proven otherwise Ear infection or pain Ear infection or pain Altered oral sensations or persistent sore throat Altered oral sensations or persistent sore throat Lesions in mouth Lesions in mouth Erythroplasia (early red lesions) Erythroplasia (early red lesions) Leukoplakia (white lesions) Leukoplakia (white lesions) Persistent mass or ulcer (usually oral cavity) Persistent mass or ulcer (usually oral cavity) Difficulties in chewing, swallowing, or moving the tongue or jaws are often late symptoms 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.

18 Head and Neck Cancer Typical Presentation Symptoms include: Symptoms include: Persisting hoarseness Persisting hoarseness Dysphagia Dysphagia Hemoptysis Hemoptysis Throat pain Throat pain Ear pain Ear pain Airway compromise Airway compromise Unexplained aspiration Unexplained aspiration Neck mass Neck mass Weight loss Weight loss

19 Larynx Cancer Presentation Hoarseness is the most common symptom Hoarseness is the most common symptom Sore throat or cough that does not go away 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 Patients presenting with new onset or worsening hoarseness should undergo indirect mirror exam and/or flexible laryngoscopy Videostroboscopy may be recommended Videostroboscopy may be recommended Good neck exam, look for cervical adenopathy Good neck exam, look for cervical adenopathy Palpate base of tongue for masses Palpate base of tongue for masses

20 HNC Evaluation Inspection and palpation Inspection and palpation Biopsy of any suspicious mucosal surface Biopsy of any suspicious mucosal surface Imaging Imaging CT, MRI CT, MRI Barium swallowing study Barium swallowing study PET/CT of value in identifying neck disease and unknown primaries 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 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 New cystic lesion in the neck unlikely to be recent onset branchial cleft cyst in an adult FNA of lymph node FNA of lymph node Examination under anesthesia Examination under anesthesia Full evaluation of the areas at risk 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.

21 Premalignant changes

22 Presentation: Nasopharynx

23 Oral Cavity Cancer Presentation

24 Tongue cancer

25 Presentation: Oropharynx Globus sensation Globus sensation Difficultly swallowing Difficultly swallowing Slurred speech Slurred speech Pain in throat or ear Pain in throat or ear Neck mass Neck mass

26 Presentation: Larynx Hoarse voice Hoarse voice Stridor Stridor Cough, hx of GERD Cough, hx of GERD Trouble swallowing Trouble swallowing For glottic tumors For glottic tumors T1-2 5% LN involvement T1-2 5% LN involvement T3-4 20% LN involvement T3-4 20% LN involvement

27 Histopathology Considerations for HNC Premalignant lesions Premalignant lesions Leukoplakia Leukoplakia Erythroplakia Erythroplakia Squamous dysplasia Squamous dysplasia Lichen planus Lichen planus Carcinoma in-situ (CIS) and early invasive squamous cell carcinoma (SCC) Carcinoma in-situ (CIS) and early invasive squamous cell carcinoma (SCC) Atypical squamous cells exhibiting nuclear atypia Atypical squamous cells exhibiting nuclear atypia Increased nuclear-to-cytoplasmic ratio Increased nuclear-to-cytoplasmic ratio Varying degrees of keratinization Varying degrees of keratinization Park BJ, et al. Cancer Biomark. 2010;9:325-339.

28 Histology 90% of H&N cancers are squamous cell carcinomas arising from the mucosal surfaces 90% of H&N cancers are squamous cell carcinomas arising from the mucosal surfaces Salivary gland tumors are typically adenocarcinomas Salivary gland tumors are typically adenocarcinomas

29 How To Treat Head and Neck Cancer Find it, usually late Find it, usually late -over 80% of tumors are late stage Surgery (cut it out) Surgery (cut it out) Radiation (burn it) Radiation (burn it) Chemotherapy (selective poisoning) Chemotherapy (selective poisoning) Combine the above Combine the above

30 Head and Neck Cancer Management Multimodality therapy for all but very early stages: surgery, radiation with adjuvant chemotherapy 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 Significant morbidity due to therapy is possible: cosmesis, decreased saliva, swallowing dysfunction, social dysfunction Novel molecular directed therapies incorporated into next generation trials Novel molecular directed therapies incorporated into next generation trials

31 Oral Cavity/Oropharynx Surgical Approaches Transoral Transoral Visor Visor Lip Split with or without mandibulotomy Lip Split with or without mandibulotomy Lip Split with Mandibulectomy Lip Split with Mandibulectomy

32 Oral Cavity/Oropharynx Surgical Approaches Transoral and Visor Approaches Transoral and Visor Approaches Cosmetic but may limit exposure Cosmetic but may limit exposure Lip Splitting Lip Splitting Modest cosmetic disadvantage with excellent posterior exposure for mandibulotomy Modest cosmetic disadvantage with excellent posterior exposure for mandibulotomy Paramedian or midline mandibulotomy Paramedian or midline mandibulotomy Avoidance of alveolar nerve Avoidance of alveolar nerve

33 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%) 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%) Increased local control with surgery + radiotherapy (60%) and improved survival (55%) Zelefsky et al, Head Neck. 1990 Nov-Dec;12(6):470-5 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 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 Fein et al. Head Neck. 1994 Jul-Aug;16(4):358-65

34 Surgical Resection Advances Reconstruction Free Tissue Transfer Free Tissue Transfer Mandibular reconstruction (fibula, scapula, etc.) Mandibular reconstruction (fibula, scapula, etc.) Soft tissue/tongue (radial forearm, rectus abdominus, lateral thigh, etc.) Soft tissue/tongue (radial forearm, rectus abdominus, lateral thigh, etc.) Resection is rarely limited by size or extent of tumor Resection is rarely limited by size or extent of tumor

35 Surgical Management Options-- Role for Minimally Invasive Approaches? Transoral laser microsurgery or robotic assisted surgery may be utilized in select patient populations Transoral laser microsurgery or robotic assisted surgery may be utilized in select patient populations Selected tumors of oropharynx and larynx Selected tumors of oropharynx and larynx HPV demographic HPV demographic Quicker recovery, faster return to swallowing, decreased rates of tracheostomy and gastrostomy tube dependence. 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 Disease free/survival outcomes appear equal to that offered by primary chemoradiation

36 Transoral Robotic Assisted Surgery--TORS Concept of De-Intensification of Therapy through TORS Concept of De-Intensification of Therapy through TORS Currently only in clinical trial setting Currently only in clinical trial setting Await the data?? Await the data?? 15-30 % of patients avoid radiation 15-30 % of patients avoid radiation Significantly lower doses and focused treatment fields when used. Significantly lower doses and focused treatment fields when used. 40-70 % patients avoid chemotherapy 40-70 % patients avoid chemotherapy Reduced rate of PEG dependency Reduced rate of PEG dependency Survival statistics equal to or surpassing other modalities Survival statistics equal to or surpassing other modalities

37 Surgical Management of Laryngeal Malignancy Premalignant lesions or Carcinoma in situ can be managed by surgical excision/stripping of the entire lesion Premalignant lesions or Carcinoma in situ can be managed by surgical excision/stripping of the entire lesion CO2 laser can be utilized CO2 laser can be utilized Early stage (T1 and T2) can be treated with radiotherapy or surgery alone, both with 85-95% cure rate 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 Surgery has shorter treatment period but may have poorer voice outcomes

38 Surgical Management of Laryngeal Malignancy Advanced stage lesions often receive surgery followed by adjuvant radiation therapy Advanced stage lesions often receive surgery followed by adjuvant radiation therapy Most T3 and T4 lesions require a total laryngectomy/pharyngectomy Most T3 and T4 lesions require a total laryngectomy/pharyngectomy Reconstruction of aerodigestive tract with loco- regional flap or free tissue transfer Reconstruction of aerodigestive tract with loco- regional flap or free tissue transfer Some small T3 and lesser sized lesions can be managed by partial laryngectomy Some small T3 and lesser sized lesions can be managed by partial laryngectomy

39 Surgical Management of Laryngeal Malignancy Modified or radical neck dissection is indicated in the presence of known nodal disease or locally advanced tumors 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 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 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 Extension to subglottic space associated with a higher incidence of stomal recurrence following total laryngectomy

40 Voice Rehabilitation After Laryngectomy Tracheoesophageal voice prosthesis Tracheoesophageal voice prosthesis Electrolarynx Electrolarynx Pure esophageal speech Pure esophageal speech Role of speech and language pathologist for rehabilitation Role of speech and language pathologist for rehabilitation

41 Case Presentation 73 Y edentulous farmer with a right gingival lesion, otherwise asymptomatic 73 Y edentulous farmer with a right gingival lesion, otherwise asymptomatic 120 PY smoking history, currently smoking 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 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 Exam shows a right lower gingival mass, 2.5 cm squamous cell carcinoma

42 Case Presentation CT demonstrates R mandibular invasion CT demonstrates R mandibular invasion

43 Case Presentation PET/CT demonstrates no evidence of metastasis PET/CT demonstrates no evidence of metastasis MR angiography demonstrates severe peripheral vascular disease in bilateral lower extremities MR angiography demonstrates severe peripheral vascular disease in bilateral lower extremities

44 Case Presentation Therapy Resection from paramedian to angle of mandible to encompass alveolar nerve Resection from paramedian to angle of mandible to encompass alveolar nerve

45 Case Presentation Treatment Options T4N0M0 squamous cell carcinoma of the right alveolus T4N0M0 squamous cell carcinoma of the right alveolus Right mandibulectomy (via visor flap), right neck dissection, fibula free flap, tracheotomy, postoperative radiation and chemotherapy 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 Transoral mandiblectomy, postoperative radiation to primary site and ipsilateral neck

46 Case Presentation Outcome Oral alimentation at 5 days postop Oral alimentation at 5 days postop External beam radiation to primary and ipsilateral neck onset 3 weeks post surgery External beam radiation to primary and ipsilateral neck onset 3 weeks post surgery Acceptable cosmetic appearance Acceptable cosmetic appearance NED at 30 mo, died shortly after from MI NED at 30 mo, died shortly after from MI

47 Questions? Contact: Charles J. Zeller, IV, DO Community ENT Care Otolaryngology Associates 317-844-7059 czeller@otolaryn.com

48 Thank You!


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