Pictorial Lesson on Head and Neck Cancer H Lord

Intra-Oral Tumours

Intraoral Cancer The majority of intraoral tumours are concentrated in the relatively small 'drainage' areas (highlighted in blue) where saliva pools

Leukoplakia Also known as smoker's keratosis, this premalignant tumour is marked by extensive, irregular, white thickening or plaques. The woman shown here habitually allowed cigarettes to burn down to the end against her lip. A carcinoma subsequently developed in this area

Tumour Staging for lip and oral cavity

Nodal Staging for Lip and oral cavity

Squamous cell carcinoma of tongue Located on the lateral border of the tongue, as is common with these tumors, this nodular lesion was painless despite its being a well-established invasive tumour.

Squamous cell carcinoma of retromolar region and soft palate. The lesion on the alveolar ridge shows the typical features of a malignant ulcer, but that of the soft palate appears only as a white patch.

Squamous cell carcinoma of floor of mouth Panoramic tomogram shows a localized area of bone destruction (arrow-heads) in the body of the mandible

Bone scan The photodeficient area (arrowheads) corresponds to the area of bone destruction seen on the tomogram. The area of increased uptake, indicating the actual extent of bone invasion, is much greater, encompassing most of the mandible.

Squamous cell carcinoma CT scan of squamous cell carcinoma involving the mandible (arrows).

Squamous cell carcinoma These well-differentiated tumours demonstrate the variable stromal response that may be encountered, ranging from (a) a heavy, chronic inflammatory infiltrate surrounding the invasive tumour, or (b) an inflammation-free stroma marked by fibroblastic proliferation. Note the presence of numerous keratin pearls.

Squamous cell carcinoma Poorly differentiated tumours are marked by sheets of immature cells and no evidence of keratinization. Neoplastic cells show extreme degrees of pleomorphism, often with bizarre mitoses

Pharyngeal Tumours

Staging of Pharyngeal Cancer

Nodal Staging and Mets for nasopharyngeal Ca

Squamous cell carcinoma of oropharynx. A 53-year-old woman presented with odynophagia and nasal regurgitation of food. Examination reveals a large, exophytic, ulcerative lesion of the left tonsil that diffusely involves the soft palate and uvula. Palatal insufficiency resulted from a fistula in the right soft palate extending into the nasopharynx. After treatment with combination chemotherapy, the lesion completely regressed, replaced by fibrous tissue, and the fistula closed. Treatment continued with definitive radiotherapy. The patient remains free of disease in long-term followup.

Squamous cell carcinoma of nasopharynx A 64-yo woman presented with a persistent serous effusion of the right middle ear. Axial CT scan: soft tissue mass in the right lateral aspect of the nasopharynx close to fossa of Rosenmuller, infiltrating deeply and involving the Eustachian tube. Fascial planes destroyed by the advancing neoplasm (compare with normal left side).

Squamous cell carcinoma of nasopharynx Coronal CT section shows a tumour extending into the middle cranial fossa (medium arrow) and inferiorly through the inferior orbital fissure (short, thick arrow), which is markedly widened (open arrow). Tumour is also present in the superior aspect of the nasal cavity (thin arrow). There is a soft tissue thickening within the sphenoid sinus.

Squamous carcinoma of nasopharynx A 35-year-old woman complained of nasal stuffiness. Sagittal T1-weighted MRI image shows a large soft tissue mass (arrows) involving the sphenoid sinus, ethmoid sinus and clivus

Boney destruction CT scan shows the extent of bony involvement of clivus; petrous temporal bone; sphenoid bone; and ethmoid

Squamous cell carcinoma of oropharynx A 63-year-old woman presented with difficulty in swallowing and otalgia. Examination reveals an extensive lesion of the right tonsil that involves the lateral pharyngeal wall, as well as the soft palate and uvula. After biopsy, which confirmed the diagnosis, the lesion was outlined (tattooed) with India ink and treated with combination chemotherapy and radiotherapy.

Response to treatment This photograph, taken after chemotherapy but before radiotherapy, shows complete clinical regression of the tumour

Laryngeal Tumours

Staging of Laryngeal Tumours

Squamous cell carcinoma of larynx Axial CT scan at the level of the posterior lamina of the cricoid cartilage (arrow 1) shows subglottic extension of an intralaryngeal tumour mass (arrow 2). The thyroid cartilage is indicated (arrow 3) Section through the glottis (about 1 cm cephalad to the previous scan) shows that necrotic tumour extends anteriorly into the soft tissue of the neck. The central portion of the thyroid cartilage has been destroyed. The tumour encroaches on the airway and has obliterated the anterior commissure. This is classified as a T4 lesion.

Squamous cell carcinoma of larynx A 68-yo man, long history of alcohol and tobacco use, progressive dysphagia and hoarseness. Laryngoscopy reveals a large exophytic lesion of the supraglottic larynx that involves the aryepiglottic fold, the false vocal cord and the infrahyoid epiglottis. The true glottis is obscured but immobile. With the discovery of several small ipsilateral cervical lymph nodes, the patient was felt to have stage IV (T3N2b) disease. Radiotherapy was administered when the patient refused surgical resection. 28 months after radiotherapy, there is no evidence of tumour.

Sinus Tumours

Staging of Tumours of the Sinuses

Squamous cell carcinoma of maxillary sinus Coronal CT scan shows intraorbital extension from a large carcinoma arising in the right maxillary sinus. The tumour extends medially into the nasal cavity, superiorly into the ethmoid labyrinth, and anterolaterally into the oral cavity. There is obvious extension of tumour into the orbit with destruction of the normal bony landmarks; the floor of the orbit (roof of the maxillary sinus) is fragmented (compare with left orbit). In this plane, the bony floor of the anterior cranial fossa appears intact. A fluid level is present in the left maxillary sinus.

Carcinoma of ethmoid sinus CT scans show a tumor expanding the ethmoid sinus, destroying the medial orbital wall and invading posteriorly into the middle cranial fossa.

Esthesioneuroblastoma A 16-year-old boy presented with nasal obstruction of recent onset. (a) Axial CT scan shows a large expansile mass (arrows) in the right nasal cavity. The medial wall of the orbit is bowed outward, displacing the globe laterally. The anteromedial wall of the maxillary sinus is displaced but appears intact.

Tumours of the Salivary Glands

T categories and stage grouping for cancer of the major salivary glands

Pleomorphic adenoma of parotid gland. Clinically, as is common with these tumours, there is a painless swelling; in this instance, the tumour involves the lower pole of the gland.

Lymphoma

Diffuse large cell lymphoma of oropharynx Additional evaluation of this 33-year-old man who presented with right tonsillar enlargement revealed only this jugulodigastric mass; biopsy yielded the histologic diagnosis. For clinical stage II disease, he received six cycles of combination chemotherapy, which resulted in a complete response. He remains disease free 8 years after treatment.

Diffuse large cell lymphoma Clinical stage I disease. This axial MR scan reveals a soft tissue mass within the neck consistent with malignant regional adenopathy. The homogeneous texture of the lesion favours a diagnosis of lymphoma which was confirmed after an initial, unremarkable, evaluation of the head and neck mucosal surfaces under aneasthesia by a head and neck surgeon and subsequent excisional biopsy of the neck lesion.

Diffuse large cell lymphoma of oropharynx A 24-year-old man, a non-smoker, presented with a 3-week history of odynophagia and fatigue refractory to a trial of antibiotics. A massive necrotic lesion of the right tonsil is apparent. Intraoral biopsy yielded the histologic diagnosis