Dr. Szekanecz ÉvaHNC HNC

Eva Szekanecz M.D., Ph.D.

CANCERS OF THE HEAD AND CANCERS OF THE HEAD AND NECKNECK

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 stagesadvanced stages ( bad QL) ( bad QL) not ‘enough’ therapeutic modalitiesnot ‘enough’ therapeutic modalities male dominancy 3:1 (?)male dominancy 3:1 (?)

ETIOLOGYETIOLOGY

SPIRITSSPIRITSSMOKINGSMOKINGpoor 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

LOCALISATIONLOCALISATION

1. oral cavity1. oral cavity 2. pharynx2. pharynx 3. larynx3. larynx 4. salivary glands4. salivary glands 5. nasal cavity and paranasal sinuses5. nasal cavity and paranasal sinuses 6. external and middle ear6. external and middle ear 7. unknown primary7. unknown primary (8. thyroid gland)(8. thyroid gland)

HISTOLOGYHISTOLOGY

CARCINOMACARCINOMA (more than 90%) (more than 90%)+ basalioma+ basalioma lymphoepitheliomalymphoepithelioma lymphomaslymphomas metastatic tumorsmetastatic tumors melanomamelanoma sarcomasarcoma

SYMPTOMSSYMPTOMS

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

painpain weight lossweight loss resulted also from problems of resulted also from problems of

alimentation and the malignant processalimentation and the malignant process

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 (KPS, WHO)performance status (KPS, WHO) physical examination (palpation and physical examination (palpation and

endoscopy included!)endoscopy included!) blood tests blood tests (markers???) (markers???) imaging techniquesimaging techniques

x -ray, ultrasonography, CT, MRIx -ray, ultrasonography, CT, MRI biopsiesbiopsies bone scansbone scans PETPET

TREATMENTTREATMENT

COMBINED ONCOTHERAPYCOMBINED ONCOTHERAPY with different with different modalitiesmodalities

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

less in advanced stages ( rather radical) less in advanced stages ( rather radical) ««

ablasticity!ablasticity! aim: organ preserving, function sparing methods aim: organ preserving, function sparing methods

with good QL and aesthetic resultswith good QL and aesthetic results

CHEMOTHERAPYCHEMOTHERAPY

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

perfusionperfusion-- neoadjuvantneoadjuvant-- adjuvantadjuvant-- palliativepalliative

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

IRRADIATIONIRRADIATION

before radiation therapy of the head and before radiation therapy of the head and neck, stomatological treatment required!neck, stomatological treatment required!

((osteoradionecrosisosteoradionecrosis))

-- 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 : 70-90% curativeT1-2N0M0 : 70-90% curative T3-4N+: 30-70% T3-4N+: 30-70% (resecable / irresecable?)(resecable / irresecable?)

PARTIAL ~

RADICAL ~

NECK DISSECTIONNECK DISSECTION (FND, RND, etc.), RND, etc.)

palliative surgery, tracheotomy

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

clinical examination,blood tests, chest x-ray, clinical examination,blood tests, chest x-ray, cervical and abdominal ultrasonography, cervical and abdominal ultrasonography, CT/MRI, (in case biopsy)CT/MRI, (in case biopsy)

ORAL CAVITY, PHARYNX ORAL CAVITY, PHARYNX AND LARYNXAND LARYNX

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

~90% differentiated squamous cell carcinoma~90% differentiated squamous cell carcinoma lymphatic metast. soon ( rich lymphatic lymphatic metast. soon ( rich lymphatic

network) - network) - often bilateral or contralateral according to often bilateral or contralateral according to crossing lymphatic drainage!crossing lymphatic drainage!

no specific symptoms (pain, bleeding,weight no specific symptoms (pain, bleeding,weight loss), RATHER RELATED TO the loss), RATHER RELATED TO the LOCALISATION (chewing, swallowing, LOCALISATION (chewing, swallowing, speaking, breathing problems, hoarsness)speaking, breathing problems, hoarsness)

MAJOR SALIVARY GLANDSMAJOR SALIVARY GLANDS

80% parotid tumours /facial nerve!/ 80% parotid tumours /facial nerve!/ -from those, 20% malignant -from those, 20% malignant (from 5-10% submandibular and 1% sublingual tumors, 45% (from 5-10% submandibular and 1% sublingual tumors, 45% and 90% malignant, respectively)and 90% malignant, respectively)

tumors arising from the minor glands are tumors arising from the minor glands are staged according to the anatomic site of staged according to the anatomic site of origin (oral cavity, sinuses, etc.)origin (oral cavity, sinuses, etc.)

symptoms: pain, asymmetrical face and symptoms: pain, asymmetrical face and movement, problems of salivation, xerostomy, movement, problems of salivation, xerostomy, fixed tumor, facial nerve palsyfixed tumor, facial nerve palsy

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

SINONASAL TUMORSSINONASAL TUMORS rare tumors, most - originated from the maxillary rare tumors, most - originated from the maxillary

sinus sinus in the 7th decade (never under 40 ys) in the 7th decade (never under 40 ys) symptoms: facial asymmetry, pain, smelling symptoms: facial asymmetry, pain, smelling

disfunctiondisfunction most of them are cancer, further melanomas or most of them are cancer, further melanomas or

lymphomaslymphomas poor prognosis (bone arrosion, mutilating poor prognosis (bone arrosion, mutilating

surgery)surgery) close to critical structures, like: eyes, skull base, close to critical structures, like: eyes, skull base,

infratemporal fossa, pterygoidsinfratemporal fossa, pterygoids

EXTERNAL AND MIDDLE EAREXTERNAL AND MIDDLE EAR

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

mostly: basaliomas, melanomas and carcinomas

distant metastases don’t occursymptoms: pain, bleeding, hearing

disorder, tinnitus, otorrhea

TUMORS OF UNKNOWN TUMORS OF UNKNOWN PRIMARYPRIMARY

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!

because the resulted changes of natural because the resulted changes of natural developement of the disease - (only developement of the disease - (only localisation must be found before therapy!)localisation must be found before therapy!)