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!)
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