Head & Neck SCCHead & Neck SCC(HNSCC)(HNSCC)Over ViewOver View

Dr Shafiq Chughtai Dr Shafiq Chughtai

PGT SU IIPGT SU II

Regions Regions

Skin Skin Oral Cavity Oral Cavity (lip ,oral cavity , oral tongue , floor of (lip ,oral cavity , oral tongue , floor of

mouth , alveolus and gingiva , retromolar trigone , buccal mouth , alveolus and gingiva , retromolar trigone , buccal mucosa)mucosa)

Phyranx Phyranx (naso , oro , hypo)(naso , oro , hypo)

LyranxLyranx Nose and Para nasal sinusNose and Para nasal sinus Ear and temporal bone Ear and temporal bone

Skin SCCSkin SCC

AetiologyAetiology

Solar Radiation Solar Radiation UV – A , UV – B , UV – C.UV – A , UV – B , UV – C. Fair skin , melanin contentFair skin , melanin content High risk at equater then lattitudes High risk at equater then lattitudes

HPV (perinium)HPV (perinium)

Clinical Features Clinical Features

Red , scaly , ulcerated patch of skin Red , scaly , ulcerated patch of skin

Types Types Protuberent Protuberent Infilterative Infilterative

Pain along the distribution of nerve Pain along the distribution of nerve

(perineural invasion)(perineural invasion)

Ulcerated growth --- everted edgesUlcerated growth --- everted edges

Head and neck SCC have better Head and neck SCC have better prognosis then else ware in the body prognosis then else ware in the body

Diagnostic Inx is excisonal biopsyDiagnostic Inx is excisonal biopsy

Management Management

Non Cuteneous HNSCCNon Cuteneous HNSCC

Aetiology Aetiology

Tobacco Tobacco

1.9 x males , 3x females1.9 x males , 3x females 40% have recurrance of malignacy if they 40% have recurrance of malignacy if they

continue to smoke as compared to 6 % continue to smoke as compared to 6 % Reverse smoking 47x hard palate Reverse smoking 47x hard palate

Alcohol Alcohol 1.7 x males with 1-2 drinks / day 1.7 x males with 1-2 drinks / day

Betal nut chewing , HPV .Betal nut chewing , HPV .

Solar radiation for lip Ca (lower lip)Solar radiation for lip Ca (lower lip)

Immunocompromised Immunocompromised Renal transplant 30 x riskRenal transplant 30 x risk AIDS AIDS

p53 mutations are blamed in > 50% of p53 mutations are blamed in > 50% of HNSCCHNSCC

Most of the pts are elderly with co morbid Most of the pts are elderly with co morbid states and malnutrionedstates and malnutrioned

Synchronous Vs MetasynchronousSynchronous Vs Metasynchronous

Over all rate of 2Over all rate of 2ndnd HNPCC coexisting in same HNPCC coexisting in same patient is 14%patient is 14%

If found within 6 months SynchronousIf found within 6 months Synchronous

If found after 6 months Meta synchronous, 80%If found after 6 months Meta synchronous, 80%

Cessation of drinking and smoking is mandatory Cessation of drinking and smoking is mandatory to reduce syn/metasyn lesions (40% vs 6 %)to reduce syn/metasyn lesions (40% vs 6 %)

Investigations Investigations

CT , MRI CT , MRI

Pan Endoscopy Pan Endoscopy (inspection and biopsy)(inspection and biopsy)

LyrangeoscopyLyrangeoscopy EsophagoscopyEsophagoscopy Bronchoscopy Bronchoscopy

AJCC Staging AJCC Staging

Oral Cavity Oral Cavity

Extends from vermilion border to hard /soft Extends from vermilion border to hard /soft palate junction superiorly , circumvallate palate junction superiorly , circumvallate papillae inferiorly and anterior tonsillar papillae inferiorly and anterior tonsillar pillars laterally pillars laterally

Has 7 sites Has 7 sites

Oral Regions

LIPORAL

TONGUEFLOOR MOUTH

ALVEOLUS / GINGIVA

RETROMOLAR

TRIGONE

BUCCALMUCOSA

PALATE

Lip Lip

Peak incidence 50-70 yrs , more in fair Peak incidence 50-70 yrs , more in fair skinned.skinned.

88-98% lower lip , 2-7% upper lip , 1% oral88-98% lower lip , 2-7% upper lip , 1% oral

commissurecommissure

Clinically ulcerated , crusty lesion which Clinically ulcerated , crusty lesion which fails to heal over a period of time.fails to heal over a period of time.

Nodal mets occour to submental / Nodal mets occour to submental / submandibular nodes in less then 10%submandibular nodes in less then 10%

Management is same as cuteneous Management is same as cuteneous HNSCC.HNSCC.

Reconstruction Reconstruction

Estlander flap Estlander flap

Karapandzic labioplasty Karapandzic labioplasty

Estlander flapEstlander flap

Karapandzic labioplastyKarapandzic labioplasty

Bad prognostic markers Bad prognostic markers Age less then 40 yrs , maxilla or mandibular Age less then 40 yrs , maxilla or mandibular

involvement , perineural invasion , Upper lipinvolvement , perineural invasion , Upper lip

5 yr survival is 90% in node –ve and 50% 5 yr survival is 90% in node –ve and 50% in node +ve disease.in node +ve disease.

Oral Tongue Oral Tongue

Exophytic / ulcerated mass on ventral and Exophytic / ulcerated mass on ventral and lateral surface of tongue.lateral surface of tongue.

Lingual nerve (impaired taste) & Lingual nerve (impaired taste) & hypoglossal nerve(tongue deviation)hypoglossal nerve(tongue deviation)

Management Management

Reconstruction Reconstruction

Surgery , in T3/T4 involves partial or total Surgery , in T3/T4 involves partial or total glossectomy glossectomy

Palliative tracheostomy and feeding Palliative tracheostomy and feeding jejunostomy may be indicated in advanced jejunostomy may be indicated in advanced caescaes

Floor of Mouth Floor of Mouth

Anterior tonsillar pillar to frenulum Anterior tonsillar pillar to frenulum anteriorly , inner surface of mandible to anteriorly , inner surface of mandible to ventral surface of tongue ventral surface of tongue

Muscular involvement ---mastication and Muscular involvement ---mastication and articulation problems articulation problems

Anterior and lateral extension involves Anterior and lateral extension involves mandiblemandible

Submandibular and sublingual glands are Submandibular and sublingual glands are commonly involvedcommonly involved

Treatment is similar to tongue CATreatment is similar to tongue CA

Resection may require segmental Resection may require segmental mandibulectomy mandibulectomy

Alveolus / Gingiva Alveolus / Gingiva

Alveolar mucosa is tightly adherent to Alveolar mucosa is tightly adherent to underlying bone , bony involvement is underlying bone , bony involvement is common.common.

MRI is best to assess bony involvementMRI is best to assess bony involvement

Rx principal is same as tongue CaRx principal is same as tongue Ca

Access is via anterior mandibulectomy / Access is via anterior mandibulectomy / segmental mandibulectomysegmental mandibulectomy

Retromolar trigone Retromolar trigone

Posterior inferior alveolar ridge to inner Posterior inferior alveolar ridge to inner surface ramus of mandiblesurface ramus of mandible

Bone involvement common due to lack of Bone involvement common due to lack of soft tissuesoft tissue

Masatter ----trismus , mandible , Masatter ----trismus , mandible , orophyranx , base of skullorophyranx , base of skull

Rx is marginal / segmental Rx is marginal / segmental mandibulectomy with reconstruction mandibulectomy with reconstruction

Ipsilateral ELND is always done due to Ipsilateral ELND is always done due to high risk of mets.high risk of mets.

Thus mandibulotomy is used to assess Thus mandibulotomy is used to assess intra oral lesions specially floor of mouth , intra oral lesions specially floor of mouth , alveolus and gingiva and retromolar alveolus and gingiva and retromolar trigone lesions.trigone lesions.

Rx principal ~ as Ca tongue.Rx principal ~ as Ca tongue.

Buccal mucosaBuccal mucosa

Inner surface of lip to alveolar ridgeInner surface of lip to alveolar ridge

Drains primarily to submandibular groupDrains primarily to submandibular group

Rx principal sameRx principal same

Recon involve multidisciplinary approach Recon involve multidisciplinary approach

Palate Palate

Semi lunar area – between inner surface Semi lunar area – between inner surface superior alveolar ridge superior alveolar ridge

Reverse smoking 47 X Reverse smoking 47 X

Greater palatine nerve involvement is very Greater palatine nerve involvement is very common so biopsy is madatory common so biopsy is madatory

Surgery Surgery

With out bony involvement , wide local With out bony involvement , wide local excisionexcision

With bony involvement – multidisciplinary With bony involvement – multidisciplinary approach + dental prosthesis approach + dental prosthesis

Phyranx Phyranx

PHYRANX

ORO

(soft palate - valacullae)

NASOPost nasal septum

To plane hard / soft palate

HYPOValacullae

To Lower border cricoid

Naso phyranx Naso phyranx

EBV and smokingEBV and smoking

Clinically Clinically Nasal obstruction Nasal obstruction Epistaxis Epistaxis Ottiti media , OtalgiaOttiti media , Otalgia Base of skull ---V,IX,X palsies Base of skull ---V,IX,X palsies

Surgery Surgery

Transpalatal Transpalatal

TransmaxillaryTransmaxillary

Anterior cranial fossa approachAnterior cranial fossa approach

Chemotherapy for early disease Chemotherapy for early disease Cisplatin + 5FUCisplatin + 5FU

Metastatic diseaseMetastatic disease RadiotherapyRadiotherapy

Orophyranx Orophyranx

Contains base of tongue , soft palate , Contains base of tongue , soft palate , uvula , tonsillar pillar , phyrangeal tonsils uvula , tonsillar pillar , phyrangeal tonsils and phyrangeal wallsand phyrangeal walls

Exophytic / ulcerated patteren common Exophytic / ulcerated patteren common

Clinically Clinically Tumor fetor (TNF)Tumor fetor (TNF) Muffled / hot potato voiceMuffled / hot potato voice Dysphagia , malnuritionDysphagia , malnurition Otalgia (IX,X)Otalgia (IX,X) Trismus (ptyregoid involvement)Trismus (ptyregoid involvement)

Nodal mets in 50% at PxNodal mets in 50% at Px

Drains to Level II,III,IV,V group + Drains to Level II,III,IV,V group + retro/paraphyrangeal nodesretro/paraphyrangeal nodes

Managemant Managemant

Cammando procedureCammando procedure

Classically described for orophyrangeal Classically described for orophyrangeal tumorstumors

Lateral wall oral phyranx , soft palate , tongue Lateral wall oral phyranx , soft palate , tongue base , ramus mandible , RND . base , ramus mandible , RND .

Nowadays MRND is used in place of RND.Nowadays MRND is used in place of RND.

When tongue base is excised , retaining When tongue base is excised , retaining the lyranx , chances of dysphagia and the lyranx , chances of dysphagia and aspiration are very high.aspiration are very high.

Lyrangectomy is done or lyranx Lyrangectomy is done or lyranx suspension procedures are done which suspension procedures are done which are very complex.are very complex.

Hypophyranx / Cervical EsophagusHypophyranx / Cervical Esophagus

Worst prognosis of HNSCCWorst prognosis of HNSCC

¾ Px with B/L paratracheal ¾ Px with B/L paratracheal lymphadenopathylymphadenopathy

Lyrangeo-phyrangeo-esophagectomy is Lyrangeo-phyrangeo-esophagectomy is done in localized disease.done in localized disease.

B/L neck dissection is rarely indicated as B/L neck dissection is rarely indicated as disease is often incurable at Pxdisease is often incurable at Px

In cervical esophagus , cricophyrangeous In cervical esophagus , cricophyrangeous involvement mandates lyrangectomy.involvement mandates lyrangectomy.

LyranxLyranx

Extends from epiglottis to lower end of Extends from epiglottis to lower end of cricoid cartilage cricoid cartilage

90% of HNSCC 90% of HNSCC

Soft tissue component of lyranx is Soft tissue component of lyranx is seperated from surrounding by fibroelastic seperated from surrounding by fibroelastic memberanes limiting Ca spreadmemberanes limiting Ca spread

Region Region Supra glottic – epiglottis to true vocal cordsSupra glottic – epiglottis to true vocal cords

Glottic – true vocal cordGlottic – true vocal cord

Infraglottic – true vocal cord to lower end Infraglottic – true vocal cord to lower end cricoid cartilage cricoid cartilage

ClinicallyClinically Supraglottic – chronic sore throat , dysphoniaSupraglottic – chronic sore throat , dysphonia

, dysphagia , dysphagia Glottic – Glottic – hoarseness of voice (early) , hoarseness of voice (early) ,

airway obstruction (late)airway obstruction (late)

Infraglottic – stridor , pain , neck mass.Infraglottic – stridor , pain , neck mass.

Supraglottic – drains along sup lyrangeal Supraglottic – drains along sup lyrangeal artery via thyrohyoid membrane to artery via thyrohyoid membrane to subdiagastric / superior lyrangeal nodessubdiagastric / superior lyrangeal nodes

Glottic / infra glottic –drains along cricoid Glottic / infra glottic –drains along cricoid ligament to prelyrangeal , pre tracheal and ligament to prelyrangeal , pre tracheal and deep cervical nodes deep cervical nodes

Early tumor Early tumor Confined to lyranx , without vocal cord fixationConfined to lyranx , without vocal cord fixation

Late tumorLate tumor Extends outside lyranx Extends outside lyranx Cord fixation Cord fixation

Early tumor Early tumor Megavoltage radiotherapy / laser ablationMegavoltage radiotherapy / laser ablation

Late tumorLate tumor Supraglottic – partial lyrangectomy in most Supraglottic – partial lyrangectomy in most Glottic / infra glottic --- total lyrangectomy Glottic / infra glottic --- total lyrangectomy Radiotherapy / chemotherapy Radiotherapy / chemotherapy

After lyrangectomy permenant tracheostomy is After lyrangectomy permenant tracheostomy is done and continuity of digestive tract restored.done and continuity of digestive tract restored.

Swallowing rehabilitation Swallowing rehabilitation

Speech rehabilitationSpeech rehabilitation Electro lyranxElectro lyranx Blom singer valve with tracheo Esophageal fistula for Blom singer valve with tracheo Esophageal fistula for

esophageal speech esophageal speech

Nose & PNSNose & PNS

Initial symptoms mimic sinositis , nasal Initial symptoms mimic sinositis , nasal obstruction .obstruction .

Late , orbital extension can cause Late , orbital extension can cause proptosis / blindness , maxillary sinus proptosis / blindness , maxillary sinus tumors can cause loosening of teethtumors can cause loosening of teeth

Evaluation of cavernous sinus , cribriform Evaluation of cavernous sinus , cribriform plate and dura is mandatoryplate and dura is mandatory

Flexible naso scope , CT and MRI are Flexible naso scope , CT and MRI are diagnostic / staging toolsdiagnostic / staging tools

Multidicipline surgical team … OMF , Multidicipline surgical team … OMF , ENT , Neuro surgeonsENT , Neuro surgeons

Radiotherapy is given post Radiotherapy is given post operatively.Chemo has limited roleoperatively.Chemo has limited role

Summary Summary

Neck Neck

Presence of nodal mets reduce survival by Presence of nodal mets reduce survival by 50% 50%

Oral cavity / lip drains into level I , II , III Oral cavity / lip drains into level I , II , III

Orophyranx , hypophyranx , lyranx drains Orophyranx , hypophyranx , lyranx drains into II , III , IV.into II , III , IV.

Hypophyranx , cervical esophagus , Hypophyranx , cervical esophagus , thyroid drains upto level VII thyroid drains upto level VII

Neck dissections Neck dissections

Elective Elective

Radical Radical

Modified radicalModified radical

Selective Selective

Elective lymph node dissection is done in Elective lymph node dissection is done in node –ve cases for prophylactic purposes node –ve cases for prophylactic purposes

Radical lymphnode dissection removes Radical lymphnode dissection removes level I-V + SCN , IJV , XIlevel I-V + SCN , IJV , XI

RND had considerable morbidity RND had considerable morbidity

Removal of one IJV increases chances of Removal of one IJV increases chances of raising ICP by 3x , if both removed , by 5 raising ICP by 3x , if both removed , by 5 X.X.

Removal of CN XI causes drooping of Removal of CN XI causes drooping of shoulder and limited movement at shoulder and limited movement at shoulder joint.shoulder joint.

Modified radical nodal dissection is ~ to Modified radical nodal dissection is ~ to RND in nodal clearence except one or all RND in nodal clearence except one or all of SCM , IJV , CN XI is preserved.of SCM , IJV , CN XI is preserved.

Selective nodal dissection preserve Selective nodal dissection preserve lymphatics as well as SCM , IJV , CN XI.lymphatics as well as SCM , IJV , CN XI.

Selective LNDSelective LND Supra omohyoid (oral cavity) , level I – IIISupra omohyoid (oral cavity) , level I – III

Lateral neck (lyrangeal malignancy) II – IVLateral neck (lyrangeal malignancy) II – IV

Posterolateral neck (thyroid) II - VPosterolateral neck (thyroid) II - V

Management Management

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