DIAGNOSIS AND TREATMENT OPTIONS IN HEAD AND NECK NEOPLASMS EVAN S. BATES, M.D. DEPT. OF...
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DIAGNOSIS AND TREATMENT OPTIONS IN
HEAD AND NECK NEOPLASMSEVAN S. BATES, M.D.
DEPT. OF OTOLARYNGOLOGY
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NASAL/SINUS TUMORSOverall incidence: 1:100,000
80% SCCA, 10% ACC/ACRisk factors: environmental exposure
DiagnosisCT/MRI, biopsy
TreatmentSurgical resectionChemotx/XRT
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This 37 yo male presented with a 4-5 week H/O an enlarging left neck mass. 3 months earlier he noted episodes of left nasal congestion with eye discomfort.
PMH: ASD repair 3/96
H/O smoking 1ppd/15 yr., quit 5 yr. go
Exam:
nasal: polypoid mucosa left inf.turbinate
oropharynx: nl.
neck: 6 x 5 cm firm, mid. Cervical mass
CASE PRESENTATION
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EVALUATIONFNAB:
+ for malignant cells immunostain profile suggests medullary CA
MRI: large left neck mass, adenopathy in levels 2-4, small
left intraparotid masses. Thyroid nl.CXR: nl.Laboratory:
calcitonin 2, CEA <0.7, TSH, LFT’s nl.
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DIFFERENTIAL DIAGNOSISLymphomaPrimary salivary neoplasm
mucoepidermoid CA, squamous CA, adenoCA
Thyroid neoplasmanaplastic CA, medullary CA
Sinus neoplasmsquamous CA, adenoCA
Unknown Head & Neck Primary
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SURGICAL MANAGEMENT
Left radical neck dissection
Left total parotidectomy
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SURGICAL FINDINGSNormal thyroid glandMultiple parotid cystsLarge left neck mass w/ additional
adenopathyFrozen section
c/w malignant neoplasmPermanent section
c/w rhabdomyosarcoma, alveolar type
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SURGICAL MANAGEMENTLeft endoscopic turbinectomy, resection
of nasal massfindings
large polypoid mass on posterior inf. Turbinate with extension superiorly along lateral nasal wall to middle meatus
pathrhabdomyosarcoma
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RHABDOMYOSARCOMA: MD ANDERSON EXPERIENCE
5 yr. Survival 44%, 60% w/combined TX.Poor survival
adult onset of diseasealveolar histology-distant mets
Symptoms:nasal obstruction (60%), facial pain (41%), facial
swelling (38%), proptosis (35%), epistaxis (27%)
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RHABDOMYOSARCOMA: UCLA EXPERIENCE
Orbit (35%), Maxillary sinus (15%)35% had CNS extension from sinus/orbitHistology not a factor in prognosisOverall survival 34%Trend toward conventional surgery
followed by intensive chemo/XRT
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RHABDOMYOSARCOMAMost common head&neck tumor in children,
rare in adults69% advanced @ presentation (Group III,IV)Ethmoid sinus most common site (46%)Nodal mets (46%), systemic mets(26%)Management: chemo/XRT/surgery7.6% 5 yr. survival
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NOSE EXAMINATION
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Usually seen in chronic sinusitis or chronic allergy patients
Topical corticosteroids of minimal benefit
Polyps require sugical excision and biopsy followed by long term allergy management
NASAL POLYPS
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OROPHARYNGEAL CARCINOMA
Usually presents with painful oral ulcerAdult males 50-70 yrs. old
Risk factors: smoking, ETOHMajority of tumors SCCA, lymphomaManagement:
Surgery/XRTXRT/CHemotx
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TONSILLAR CARCINOMA20-30% present with neck metastasesEvaluation with CT/MRI, Chest CT, PET scan,
LFT’sManagement must include neck diseaseStage I survival 80-90%, Stage IV survival 25-
40%Treatment standard involves surgery/XRT
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TONGUE NEOPLASMS3% of all CA in US, 50% of CA in India,
3rd most common malignancy in France>90% SCCA, associated with tobacco
use, ETOHSurvival rate decreased with lymphatic
involvementTreatment focused on surgery/XRTReconstruction of prime importance
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TONGUE CARCINOMATongue lesions can be resected primarily
due to tongue redundancyPrimary closure vs. local flapXRT for incomplete resection, T2 or
greater lesions or nodal disease
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TONGUE MASSNeurofibromaMucosal covered mass rather than
ulcerated lesionSurgical resection alone is sufficient
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NECK EXAMINATION
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NECK MASSES KEY TO DIAGNOSIS IS HISTORY
TIME COURSE OF MASS PAINFUL/TENDER RECENT
INFECTIONS/TRAUMA SMOKER?
PHYSICAL EXAM LOCATION OF MASS FIRM/CYSTIC/TENDER/
MULTIPLE MASSES
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NECK MASSES IF YOU SUSPECT INFECTION,
TREAT WITH 1 COURSE OF ANTIBIOTICS
IF NO RESOLUTION, REFER TO ENT EVALUATION
HEAD & NECK EXAM FNA-B CT/MRI
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NECK EXAMINATION
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Large thyroid mass suspicious for malignancy
FNA-B important Surgical resection with
CN X monitor Post-operative therapy
dependent on path
THYROID MASS
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Uncommon site for oral carcinoma
Usually managed with wide local excision
Frequently seen in pipe smokers
LIP CARCINOMA
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HOARSENESS MANAGEMENT:
REFER TO ENT IF PROLONGED OR DIAGNOSIS UNCERTAIN
INDIRECT LARYNGOSCOPY
BE SUSPICIOUS OF MALIGNANCY IN SMOKERS AT ANY AGE
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Usually seen in smokers
Extremely hoarse voice for several weeks
May have referred otalgia
Obviously needs laryngoscopy/biopsy
LARYNGEAL CARCINOMA
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LARYNGEAL CARCINOMATreatment goals shifted to larynx preservation
based on 1992 VA study11,000 new cases annually, >90% have
smoking exposure Induction chemotx/XRT preserves larynx in
64% patientsXRT for T1/T2 lesions5 yr. Survival 70-80% for T3< lesions, 40% for
T4 lesions
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LARYNX EVALUATION
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Usually a gravelly/hoarse voice History of voice
overuse/singers Voice rest may help Often associated with GERD ENT eval. for laryngoscopy
VOCAL CORD NODULE
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HOARSENESS ASSOCIATED WITH URI
SELF-LIMITED RESOLVES IN 7-21 DAYS PROLONGED RESOLUTION IN
SMOKERS MANAGEMENT
ANTIBIOTICS (S. AUREUS) HUMIDIFICATION STEROIDS
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HOARSENESS CHRONIC HOARSENESS
VOCAL OVERUSE VOCAL FOLD POLYPS GERD PRESBYLARYNGIS
ACUTE HOARSENESS IF ASSOCIATED WITH NECK
TRAUMA--ER