Presentation on theme: "Epidemiology, Anatomy, Presentation, Surgical Options"— Presentation transcript:
1 Epidemiology, Anatomy, Presentation, Surgical Options Head and Neck CancerEpidemiology, Anatomy, Presentation, Surgical OptionsCharles J. Zeller, IV, DOCommunity ENT CareOtolaryngology Associates
2 HNC: The StatisticsCancer Cases and Deaths of the Oral Cavity & Pharynx by Sex, United States, 2012MenNew Cases=28,5408th leading cause of cancer in menLifetime probability is 1 in 69New Deaths=5,440WomenNew Cases=11,710New Deaths=2,410American Cancer Society. Cancer Facts & Figures 2012.
3 U.S. Incidence Rates for HNC In 2012, >40,000 new casesIncidence more than twice as high in men as in womenFrom 2004 to 2008, incidence rates declined by 1.0% per year in women and were stable in menIncidence 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 2012Death rates have been decreasing over the past 3 decadesFrom 2004 to 2008, rates decreased by 1.2% per year in men and by 2.2% per year in womenAmerican 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, about84% survive 1 year after diagnosis61% survive 5 years after diagnosis, and50% survive 10 years after diagnosisFive-year Relative Survival Rates by Stage at Diagnosis, *Oral cavity& pharynxAll StagesLocalRegionalDistant61%82%56%34%*Rates are adjusted for normal life expectancy and are based on casesdiagnosed in the SEER 17 areas from , followed through 2008.American Cancer Society. Cancer Facts & Figures 2012.
6 Relative Survival Rate (%) by Primary HNC Site, 1988-2001 Piccirillo JF, et al. National Cancer Institute. SEER Survival Monograph. Chapter 2
7 HNC Risk Factors Known risk factors: All forms of smoked and smokeless tobacco productsExcessive consumption of alcohol30-fold increased risk for individuals who both smoke and drink heavily!HPV infection associated with cancers ofTonsilBase of tongueOther sites within the oropharynxBelieved to be transmitted through sexual contactAmerican 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.
11 Head and Neck Cancer (HNC) Oral cavityNasal antrumLip Buccal mucosa Alveolar ridge and retromolar trigone Floor of mouth Hard palate Oral tongue (anterior two thirds)NasopharynxOropharynxBase of tongue Soft palateTonsillar pillar and fossaPharynxSupraglottis False cords Arytenoids Epiglottis Arytenoepiglottic foldGlottis SubglottisHypopharynxLarynxEsophagus
14 Anatomy: Nasopharynx Eustachian tube Torus Tubaris Fossa of Rosenmuller
15 Anatomy: Oro/Hypopharynx From the uvula to hyoid bonePalatine tonsils, tonsillar pillarsBase of tongueEpiglottis and vallecula
16 Anatomy: Laryngopharynx From the epiglottis to the inferior cricoid cartilageVocal cords, piriform sinuses, arytenoid cartilage and aryepiglottic folds
17 Head and Neck Cancer Signs and Symptoms Persistent hoarsenessPalpable mass in neckBranchial cleft cysts rarely present later than young adulthoodNeck mass in persons >40 yrs of age should be considered a malignancy until proven otherwiseEar infection or painAltered oral sensations or persistent sore throatLesions in mouthErythroplasia (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 symptomsChin D, et al. Expert Rev Anticancer Ther. 2006;6:NCCN Clinical Practice Guidelines. Head and Neck Cancers. VAmerican Cancer Society. Oral Cavity and Oropharyngeal Cancer, Laryngeal and Hypopharyngeal Cancer.1717
18 Head and Neck Cancer Typical Presentation Symptoms include:Persisting hoarsenessDysphagiaHemoptysisThroat painEar painAirway compromiseUnexplained aspirationNeck massWeight loss
19 Larynx Cancer Presentation Hoarseness is the most common symptomSore throat or cough that does not go awayPatients presenting with new onset or worsening hoarseness should undergo indirect mirror exam and/or flexible laryngoscopyVideostroboscopy may be recommendedGood neck exam, look for cervical adenopathyPalpate base of tongue for masses
20 HNC Evaluation Inspection and palpation Biopsy of any suspicious mucosal surfaceImagingCT, MRIBarium swallowing studyPET/CT of value in identifying neck disease and unknown primariesCT of chest if there are neck nodes and no PET/CT as lung metastases common first distant siteNew cystic lesion in the neck unlikely to be recent onset branchial cleft cyst in an adultFNA of lymph nodeExamination under anesthesiaFull evaluation of the areas at riskNCCN Clinical Practice Guidelines. Head and Neck Cancers. VAmerican Cancer Society. Oral Cavity and Oropharyngeal Cancer, Laryngeal and Hypopharyngeal Cancer.2020
27 Histopathology Considerations for HNC Premalignant lesionsLeukoplakiaErythroplakiaSquamous dysplasiaLichen planusCarcinoma in-situ (CIS) and early invasive squamous cell carcinoma (SCC)Atypical squamous cells exhibiting nuclear atypiaIncreased nuclear-to-cytoplasmic ratioVarying degrees of keratinizationPark BJ, et al. Cancer Biomark. 2010;9:
28 Histology90% of H&N cancers are squamous cell carcinomas arising from the mucosal surfacesSalivary gland tumors are typically adenocarcinomas
29 How To Treat Head and Neck Cancer Find it, usually late-over 80% of tumors are late stageSurgery (cut it out)Radiation (burn it)Chemotherapy (selective poisoning)Combine the above
30 Head and Neck Cancer Management Multimodality therapy for all but very early stages: surgery, radiation with adjuvant chemotherapySignificant morbidity due to therapy is possible: cosmesis, decreased saliva, swallowing dysfunction, social dysfunctionNovel molecular directed therapies incorporated into next generation trials
31 Oral Cavity/Oropharynx Surgical Approaches TransoralVisorLip Split with or without mandibulotomyLip Split with Mandibulectomy
32 Oral Cavity/Oropharynx Surgical Approaches Transoral and Visor ApproachesCosmetic but may limit exposureLip SplittingModest cosmetic disadvantage with excellent posterior exposure for mandibulotomyParamedian or midline mandibulotomyAvoidance 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%)Increased local control with surgery + radiotherapy (60%) and improved survival (55%)Zelefsky et al, Head Neck Nov-Dec;12(6):470-5Local control significantly improved for locally advanced T3, T4 oral cancers using surgery + postoperative radiotherapy vs. primary RTFein et al. Head Neck Jul-Aug;16(4):358-65
34 Surgical Resection Advances ReconstructionFree Tissue TransferMandibular reconstruction (fibula, scapula, etc.)Soft tissue/tongue (radial forearm, rectus abdominus, lateral thigh, etc.)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 populationsSelected tumors of oropharynx and larynxHPV demographicQuicker 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
36 Transoral Robotic Assisted Surgery--TORS Concept of De-Intensification of Therapy through TORSCurrently only in clinical trial settingAwait the data??15-30 % of patients avoid radiationSignificantly lower doses and focused treatment fields when used.40-70 % patients avoid chemotherapyReduced rate of PEG dependencySurvival 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 lesionCO2 laser can be utilizedEarly stage (T1 and T2) can be treated with radiotherapy or surgery alone, both with 85-95% cure rateSurgery 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 therapyMost T3 and T4 lesions require a total laryngectomy/pharyngectomyReconstruction of aerodigestive tract with loco- regional flap or free tissue transferSome 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 tumorsN0 necks can have a selective neck dissection sparing SCM, IJV, and CN XISupraglottic and subglottic tumors have higher rate of occult cervical metastasis due to lymphatic drainage patternsExtension to subglottic space associated with a higher incidence of stomal recurrence following total laryngectomy
40 Voice Rehabilitation After Laryngectomy Tracheoesophageal voice prosthesisElectrolarynxPure esophageal speechRole of speech and language pathologist for rehabilitation
41 Case Presentation73 Y edentulous farmer with a right gingival lesion, otherwise asymptomatic120 PY smoking history, currently smokingPast Medical History: diabetes, coronary artery disease, myocardial infarction x 2, carotid endarterectomy, peripheral vascular disease, and hypertension, renal insufficiencyExam shows a right lower gingival mass, 2.5 cm squamous cell carcinoma
42 Case PresentationCT demonstrates R mandibular invasion
43 Case Presentation PET/CT demonstrates no evidence of metastasis 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
45 Case Presentation Treatment Options T4N0M0 squamous cell carcinoma of the right alveolusRight mandibulectomy (via visor flap), right neck dissection, fibula free flap, tracheotomy, postoperative radiation and chemotherapyTransoral mandiblectomy, postoperative radiation to primary site and ipsilateral neck
46 Case Presentation Outcome Oral alimentation at 5 days postopExternal beam radiation to primary and ipsilateral neck onset 3 weeks post surgeryAcceptable cosmetic appearanceNED at 30 mo, died shortly after from MI
47 Questions. Contact: Charles J Questions? Contact: Charles J. Zeller, IV, DO Community ENT Care Otolaryngology Associates