Dr. Szekanecz ÉvaHead and Neck CancerHead and Neck Cancer

Eva Szekanecz M.D., Ph.D.2014.

CANCERS OF THE HEAD AND NECKCANCERS OF THE HEAD AND NECK

MAY ARISE FROM ANY OF THE LINING MAY ARISE FROM ANY OF THE LINING MEMBRANES OF THE UPPER MEMBRANES OF THE UPPER AERODIGESTIVE TRACTAERODIGESTIVE TRACT

~2% of all malignancies~2% of all malignancies number of cases grow continously in certain ages number of cases grow continously in certain ages

and populationand population mortality increasesmortality increases diagnosed in more diagnosed in more advanced stages advanced stages ( bad QoL) ( bad QoL) not ‘enough’ therapeutic modalitiesnot ‘enough’ therapeutic modalities male dominancy 3:1 (?)male dominancy 3:1 (?)

ETIOLOGYETIOLOGY

SPIRITSSPIRITSSMOKING SMOKING („pack year of tobacco smoking”)(„pack year of tobacco smoking”)

poor social standingpoor social standingspicy / hot foodspicy / hot foodoral higiene (stomatological status)oral higiene (stomatological status)viruses (EBV)viruses (EBV)activity (wood, tobacco)activity (wood, tobacco)ageage and sexand sex

PROGNOSTIC FACTORSPROGNOSTIC FACTORS

smoking habits and alcohol smoking habits and alcohol ( and other continued exposure of carcinogens)( and other continued exposure of carcinogens)

sex and agesex and age localisationlocalisation and histologic type and histologic type extent extent of the mucosal lesionof the mucosal lesion importance of importance of TNMTNM factors factors histologic grade (cellular differentiation)histologic grade (cellular differentiation) averall health parameters of the patient averall health parameters of the patient

(performance status, comorbidity)(performance status, comorbidity)

LOCALISATIONLOCALISATION

1. oral cavity1. oral cavity

2. pharynx2. pharynx

3. larynx3. larynx

LOCALISATION 2.LOCALISATION 2.

4.4. salivary glandssalivary glands

nasal cavity and paranasal sinuses nasal cavity and paranasal sinuses

external and middle earexternal and middle ear

6.6. unknown primaryunknown primary

(8. thyroid gland)(8. thyroid gland)

HISTOLOGYHISTOLOGY

CARCINOMACARCINOMA (more than 90%) (more than 90%)

basaliomabasalioma lymphoepitheliomalymphoepithelioma lymphomaslymphomas metastatic tumorsmetastatic tumors melanomamelanoma sarcomasarcoma

SYMPTOMSSYMPTOMS

functional and aesthetic disorders according functional and aesthetic disorders according to location:to location: breathing, swallowing, breathing, swallowing, vocalisation, haemoptysisvocalisation, haemoptysis

painpain weight lossweight loss metastatic sitesmetastatic sites

- regional: cervical lymph nodes- regional: cervical lymph nodes- distant: lungs, liver, mediastinal lymph - distant: lungs, liver, mediastinal lymph

nodes, (skeletal bones)nodes, (skeletal bones)

CLINICAL STAGINGCLINICAL STAGING anamnestic findingsanamnestic findings performance status performance status physical examination physical examination blood tests blood tests imaging techniquesimaging techniques

x -ray, ultrasonography, CT, MRIx -ray, ultrasonography, CT, MRI biopsiesbiopsies bone scansbone scans PET scanPET scan

TREATMENTTREATMENT

COMBINED ONCOTHERAPY COMBINED ONCOTHERAPY always always INDIVIDUAL treatment planningINDIVIDUAL treatment planning organ preserving variations in earlier stages, organ preserving variations in earlier stages,

less in advanced stages less in advanced stages

↕↕ablasticity!ablasticity!

aim: organ preserving, function sparing methods organ preserving, function sparing methods with good QoL and aesthetic resultswith good QoL and aesthetic results

1111

COMBINATION ONKOTHERAPY !COMBINATION ONKOTHERAPY !

ChemoChemo-- palliativepalliative-- neoadjuvantneoadjuvant-- adjuvantadjuvant

IrradiationIrradiation-- palliativepalliative-- definitivedefinitive-- preoperativepreoperative-- postoperativepostoperative

CHEMOTHERAPYCHEMOTHERAPY

1st cytotoxic attempts 30 years ago… (MTX?)1st cytotoxic attempts 30 years ago… (MTX?) i.v. administration i.v. administration

PLATINUMPLATINUM / DDP, CBP // DDP, CBP /5, FLUOROURACIL5, FLUOROURACILTAXANESTAXANESEGFR INHIBITORSEGFR INHIBITORS

TARGETED THERAPYTARGETED THERAPY

BIOLOGICAL TREATMENTBIOLOGICAL TREATMENT

Cetuximab Cetuximab – –

Under the age of 70 ysUnder the age of 70 ys

IRRADIATIONIRRADIATION

(osteoradionecrosis…)(osteoradionecrosis…)

-- definitive definitive

-- preoperativepreoperative

-- postoperativepostoperative

-- pallativepallative

EXTERNAL BEAM EXTERNAL BEAM RTRT

BRACHYTHERAPYBRACHYTHERAPY

SURGERYSURGERY

(laser, cryo) excision with directly closing suture excision with closing flap techniques T1-2N0M0 : T1-2N0M0 : T3-4N+:T3-4N+:

PARTIAL ~

RADICAL ~

NECK DISSECTIONNECK DISSECTION (FND, RND, etc.)

palliative surgery, tracheotomy

SURVIVALSURVIVAL

OS doesn’t increase despite OS doesn’t increase despite

the developement of the developement of

oncotherapyoncotherapy

↑↑locoregionally advanced tumors locoregionally advanced tumors

are diagnosed in most of the casesare diagnosed in most of the cases

• the patients has less tolerability to more radical and/or the patients has less tolerability to more radical and/or combined treatment modalitiescombined treatment modalities

• less than 50% of patients are suitable for combined less than 50% of patients are suitable for combined RT+ chemoRT+ chemo

FOLLOW UPFOLLOW UP

1st year1st year every 2 monthsevery 2 months 2nd year2nd year every 3 monthsevery 3 months 3rd-5th year3rd-5th year every 6 monthsevery 6 months over 5 ysover 5 ys as it necessary or once a yearas it necessary or once a year

ORAL CAVITY, PHARYNX AND ORAL CAVITY, PHARYNX AND LARYNXLARYNX

rapid infiltration because of the lack of barriers in the rapid infiltration because of the lack of barriers in the soft tissuessoft tissues

~90% differenciated squamous cell carcinoma~90% differenciated squamous cell carcinoma

lymphatic metast. soon ( rich lymphatic network) -lymphatic metast. soon ( rich lymphatic network) -

no specific symptoms (pain, bleeding,weight loss), no specific symptoms (pain, bleeding,weight loss),

MAJOR SALIVARY GLANDSMAJOR SALIVARY GLANDS 80% parotid tumours /facial nerve!/ 80% parotid tumours /facial nerve!/

- from those 20% malignant - from those 20% malignant

symptoms: pain, asymetric face movement, problems : pain, asymetric face movement, problems of salivation, xerostomy, fixed tumor, facial nerve of salivation, xerostomy, fixed tumor, facial nerve palsypalsy

recurrence can occur even over 5 years !!! recurrence can occur even over 5 years !!!

SINONASAL TUMORSSINONASAL 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: facial asymmetry, pain, smelling disfunction

poor prognosis (bone arrosion, mutilating surgery)poor prognosis (bone arrosion, mutilating surgery)

EXTERNAL AND MIDDLE EAREXTERNAL AND MIDDLE EAR

rare, painful tumors (1st: pinna, 2 nd: external tube)

mostly: basaliomas, melanomas and carcinomas

symptoms: pain, bleeding, hearing disorder, tinnitus, otorrhea

TUMORS OF UNKNOWN PRIMARYTUMORS OF UNKNOWN PRIMARY

signs of the metastasis point to the primary signs of the metastasis point to the primary localisationlocalisation

histological heterogenity histological heterogenity

poor prognosis (survival:3-5 months)poor prognosis (survival:3-5 months)

CLINICAL INVESTIGATION HAS TO BE CLINICAL INVESTIGATION HAS TO BE COMPLETED BEFORE ANY TREATMENT!COMPLETED BEFORE ANY TREATMENT!