1. Dr. Szekanecz Éva HNC Eva Szekanecz M.D., Ph.D.

2. CANCERS OF THE HEAD AND NECK MAY ARISE FROM ANY OF THE LINING MEMBRANES OF THE UPPER AERODIGESTIVE TRACT MAY ARISE FROM ANY OF THE LINING MEMBRANES OF THE UPPER AERODIGESTIVE TRACT ~2% of all malignancies ~2% of all malignancies number of cases grow continously in certain ages and population number of cases grow continously in certain ages and population mortality increases mortality increases diagnosed in more advanced stages ( bad QL) diagnosed in more advanced stages ( bad QL) not ‘enough’ therapeutic modalities not ‘enough’ therapeutic modalities male dominancy 3:1 (?) male dominancy 3:1 (?)

3. ETIOLOGY SPIRITS SPIRITS SMOKING SMOKING poor social standing poor social standing spicy / hot food spicy / hot food oral higiene (stomatological status) oral higiene (stomatological status) viruses (EBV) viruses (EBV) activity (wood, tobacco) activity (wood, tobacco) age and sex age and sex

4. LOCALISATION 1. oral cavity 1. oral cavity 2. pharynx 2. pharynx 3. larynx 3. larynx 4. salivary glands 4. salivary glands 5. nasal cavity and paranasal sinuses 5. nasal cavity and paranasal sinuses 6. external and middle ear 6. external and middle ear 7. unknown primary 7. unknown primary (8. thyroid gland) (8. thyroid gland)

5. HISTOLOGY CARCINOMA (more than 90%) CARCINOMA (more than 90%) + basalioma + basalioma lymphoepithelioma lymphoepithelioma lymphomas lymphomas metastatic tumors metastatic tumors melanoma melanoma sarcoma sarcoma

6. SYMPTOMS functional and aesthetic disorders according to localisation: breathing, swallowing, vocalisation, haemoptysis functional and aesthetic disorders according to localisation: breathing, swallowing, vocalisation, haemoptysis pain pain weight loss resulted also from problems of alimentation and the malignant process weight loss resulted also from problems of alimentation and the malignant process metastatic sites metastatic sites - regional: cervical lymph nodes - distant: lungs, liver, mediastinal lymph nodes, (skeletal bones)

7. CLINICAL STAGING anamnestic findings anamnestic findings performance status (KPS, WHO) performance status (KPS, WHO) physical examination (palpation and endoscopy included!) physical examination (palpation and endoscopy included!) blood tests (markers???) blood tests (markers???) imaging techniques imaging techniques x -ray, ultrasonography, CT, MRI biopsies biopsies bone scans bone scans PET PET

8. TREATMENT COMBINED ONCOTHERAPY with different modalities COMBINED ONCOTHERAPY with different modalities always INDIVIDUAL treatment planning always INDIVIDUAL treatment planning organ preserving variations in earlier stages, less in advanced stages ( rather radical) « organ preserving variations in earlier stages, less in advanced stages ( rather radical) «ablasticity! aim: organ preserving, function sparing methods with good QL and aesthetic results aim: organ preserving, function sparing methods with good QL and aesthetic results

9. CHEMOTHERAPY 1st cytotoxic attempts 30 years ago… (MTX?) 1st cytotoxic attempts 30 years ago… (MTX?) i.v. administration instead of intraarterial perfusion i.v. administration instead of intraarterial perfusion -neoadjuvant -adjuvant -palliative PLATINUM / DDP, CBP / 5, FLUOROURACIL TAXANES EGFR INHIBITORS

10. IRRADIATION before radiation therapy of the head and neck, stomatological treatment required! before radiation therapy of the head and neck, stomatological treatment required! (osteoradionecrosis) -definitive -preoperative -postoperative -pallative EXTERNAL BEAM RT BRACHYTHERAPY

11. SURGERY (laser, cryo) excision with directly closing suture excision with closing flap techniques T1-2N0M0 : 70-90% curative T1-2N0M0 : 70-90% curative T3-4N+: 30-70% (resecable / irresecable?) T3-4N+: 30-70% (resecable / irresecable?) PARTIAL ~ RADICAL ~ NECK DISSECTION, RND, etc.) NECK DISSECTION (FND, RND, etc.) palliative surgery, tracheotomy

12. FOLLOW UP 1st yearevery 2 months 1st yearevery 2 months 2nd yearevery 3 months 2nd yearevery 3 months 3rd-5th year every 6 months 3rd-5th year every 6 months over 5 ysas it necessary or once a year over 5 ysas it necessary or once a year clinical examination,blood tests, chest x-ray, cervical and abdominal ultrasonography, CT/MRI, (in case biopsy)

13. ORAL CAVITY, PHARYNX AND LARYNX rapid infiltration because of the lack of barriers in the soft tissues rapid infiltration because of the lack of barriers in the soft tissues ~90% differentiated squamous cell carcinoma ~90% differentiated squamous cell carcinoma lymphatic metast. soon ( rich lymphatic network) - often bilateral or contralateral according to crossing lymphatic drainage! lymphatic metast. soon ( rich lymphatic network) - often bilateral or contralateral according to crossing lymphatic drainage! no specific symptoms (pain, bleeding,weight loss), RATHER RELATED TO the LOCALISATION (chewing, swallowing, speaking, breathing problems, hoarsness) no specific symptoms (pain, bleeding,weight loss), RATHER RELATED TO the LOCALISATION (chewing, swallowing, speaking, breathing problems, hoarsness)

14. MAJOR SALIVARY GLANDS 80% parotid tumours /facial nerve!/ 80% parotid tumours /facial nerve!/ -from those, 20% malignant (from 5-10% submandibular and 1% sublingual tumors, 45% and 90% malignant, respectively) tumors arising from the minor glands are staged according to the anatomic site of origin (oral cavity, sinuses, etc.) tumors arising from the minor glands are staged according to the anatomic site of origin (oral cavity, sinuses, etc.) symptoms: pain, asymmetrical face and movement, problems of salivation, xerostomy, fixed tumor, facial nerve palsy symptoms: pain, asymmetrical face and movement, problems of salivation, xerostomy, fixed tumor, facial nerve palsy recurrence can occur even over 5 years !!! recurrence can occur even over 5 years !!!

15. SINONASAL TUMORS rare tumors, most - originated from the maxillary sinus rare tumors, most - originated from the maxillary sinus in the 7th decade (never under 40 ys) in the 7th decade (never under 40 ys) symptoms: facial asymmetry, pain, smelling disfunction symptoms: facial asymmetry, pain, smelling disfunction most of them are cancer, further melanomas or lymphomas most of them are cancer, further melanomas or lymphomas poor prognosis (bone arrosion, mutilating surgery) poor prognosis (bone arrosion, mutilating surgery) close to critical structures, like: eyes, skull base, infratemporal fossa, pterygoids close to critical structures, like: eyes, skull base, infratemporal fossa, pterygoids

16. EXTERNAL AND MIDDLE EAR rare, painful tumors (1st: pinna, 2 nd: external tube) mostly: basaliomas, melanomas and carcinomas distant metastases don’t occur symptoms: pain, bleeding, hearing disorder, tinnitus, otorrhea

17. TUMORS OF UNKNOWN PRIMARY signs of the metastasis point to the primary localisation signs of the metastasis point to the primary localisation histological heterogenity histological heterogenity poor prognosis (survival:3-5 months) poor prognosis (survival:3-5 months) CLINICAL INVESTIGATION HAS TO BE COMPLETED BEFORE ANY TREATMENT! CLINICAL INVESTIGATION HAS TO BE COMPLETED BEFORE ANY TREATMENT! because the resulted changes of natural developement of the disease - (only localisation must be found before therapy!)