1. Adult Neck Masses Ian Paquette MD DHMC PGY 3-5 Teaching Conference 12/20/2006

2. Head and Neck Tumors Epithelial Tumors Squamous Cell Carcinoma (>90%) Squamous Cell Carcinoma (>90%) Salivary Gland Salivary Gland Adenocarcinoma Adenocarcinoma Thyroid Thyroid Melanoma Melanoma Neuroepithelial tumors Neuroepithelial tumors Connective Tissue tumors Connective Tissue tumors Lymphoma Lymphoma Sarcoma Sarcoma

3. Clinical Presentation *In a smoker > 35 years old, these symptoms suggest head and neck cancer until proven otherwise Odynophagia Odynophagia Dysphagia Dysphagia Weight Loss Weight Loss Loose Dentition Loose Dentition Oral Fetor Oral Fetor Trismus Trismus Otalgia Otalgia Neck Mass Neck Mass Serous Otitis Media Serous Otitis Media Nasal Obstruction Nasal Obstruction Epistaxis Epistaxis Facial Pain Facial Pain Cranial Neuropathies Cranial Neuropathies Secondary Infections Secondary Infections Aspiration Aspiration Fistulization Fistulization Hemorrhage Hemorrhage Airway Obstruction Airway Obstruction

4. Evaluation Tobacco/Alcohol – Synergistic effect Tobacco/Alcohol – Synergistic effect –15 fold risk of squamous cell carcinoma of the head and neck compared to the general population o Occupational Factors - e.g., nickel workers, wood workers implicated in paranasal sinus cancer o Epstein-Barr Virus (EBV) - Possible etiological role in nasopharyngeal carcinoma o Radiation - Increased risk of thyroid cancer, parotid neoplasms, malignant degeneration of papillomas and possibly other upper aerodigestive tract neoplasms

5. Evaluation Physical Exam Physical Exam –Head and Neck Examination - both inspection and palpation especially oral cavity, base of the tongue, and palate –General Physical Examination - distant metastases, coexisting medical problems

6. Evaluation Biopsy - histologic confirmation of the diagnosis is mandatory before pursuing definitive therapy Superficial lesions - punch biopsy - ideal for readily accessible lesions of the skin or mucosa Superficial lesions - punch biopsy - ideal for readily accessible lesions of the skin or mucosa Deeper lesions Deeper lesions –Fine needle aspiration with cytology –Large bore needle –Incisional biopsy - violates capsule and potentially seeds tumor. Useful when all diagnostic modalities have failed to establish a diagnosis and excisional biopsy of the mass is not technically feasible. –Excisional biopsy - removal of a suspected tumor mass in its entirety. Rarely indicated in squamous cell carcinomas of the upper aerodigestive tract.

7. Indications for FNA Progressively enlarging nodes Progressively enlarging nodes A single asymmetric node A single asymmetric node A persistent nodal mass without antecedent active signs of infection A persistent nodal mass without antecedent active signs of infection Actively infectious condition that does not respond to conventional antibiotics Actively infectious condition that does not respond to conventional antibiotics

8. If no primary is found on exam Panendoscopy under anesthesia Panendoscopy under anesthesia –Nasopharyngoscopy –Direct laryngoscopy –Bronchoscopy –Esophagoscopy –In most cases this identifies the primary and will allow appropriate biopsies to be taken

9. If there is STILL no evidence of a primary? Random biopsies Random biopsies –Nasopharynx –Piriform Sinus –Base of tongue –Tonsillar fossa

10. Staging Panendoscopy under general anesthesia Panendoscopy under general anesthesia –Direct Laryngoscopy –Esophagoscopy –Tracheobronchoscopy Important due to a 5-15% incidence of synchronous tumors Important due to a 5-15% incidence of synchronous tumors

11. TABLE 42.5 CORRELATION OF PRIMARY SITE AND STAGE OF HEAD AND NECK CANCER WITH SURVIVAL RATES Primary site Survival rate (%) a a Stage IStage IIStage IIIStage IV ORAL CAVITY Tongue70504020 Floor of mouth70502510 Buccal mucosa75653020 Alveolar ridge80653515 PHARYNX Nasopharynx80604020 Oropharynx80603020 Hypopharynx60503010 LARYNX Supraglottic75605025 Glottic95805030 Subglottic b b a These numbers represent approximate averages; wide ranges have been reported for all sites and stages. b Too rare for meaningful survival data. T1 > 2 cm, T2 2 – 4 cm T3 > 4 cm T4 invasion of antrum N0 – no positive nodes N1 – single node < 3 cm N2a – single node 3 – 6 cm N2b – multiple unilateral nodes < 6 cm N2c – multiple bilateral nodes < 6 cm N3 -- Nodes > 6 cm M (distant metastasis) Stages I T1M0N0 II T2N0M0 III T3N0M0 T1-3,N1M0 T1-3,N1M0 IV T1-3,N2-3M0 T1-3N0-3M1 T1-3N0-3M1 Squamous Cell Carcinoma

12. Treatment The principles of therapy of head and neck cancer directed at cure of the disease should try to meet three objectives: The principles of therapy of head and neck cancer directed at cure of the disease should try to meet three objectives: –To eradicate the neoplasm completely –To give the patient the best functional result by careful planning of the radiation fields or appropriate reconstructive techniques for surgical defects –To leave the patient with as good a cosmetic result as possible

13. Treatment Multimodality treatments Multimodality treatments –Important to discuss at multi-specialty tumor boards Alcohol/Tobacco cessation Alcohol/Tobacco cessation –Up to 40% risk of recurrence –10-40% risk of developing a 2 nd primary

14. Stage 1 and 2 Radiation or Surgery Radiation or Surgery –Offer similar results –Choice depends on the exact site of the primary and the surgeon’s preference

15. Stage 3 Surgical Treatment Surgical Treatment –Complete Resection plus reconstruction –Often need postoperative radiation –+/- Adjuvent Chemotherapy on an individualized basis

16. Stage 4 Chemotherapy Chemotherapy –Cisplatin, 5-FU, etc Palliative Surgery Palliative Surgery

17. Follow-Up Monitor the patient's response to therapy Monitor the patient's response to therapy To detect recurrence or second primary To detect recurrence or second primary –Every two months in the first year –Every three months the second and third year –At least every six months in the fourth and fifth years –Yearly thereafter

18. Salivary Gland Tumors Major Salivary Glands Major Salivary Glands –Parotid, submandibular, sublingual Minor Salivary glands Minor Salivary glands – found in the submucosa of the nose, mouth, sinuses, and upper aerodigestive tract Tumors can occur in either major or minor glands Tumors can occur in either major or minor glands

19. Salivary Gland Tumors Parotid Gland: 80% of salivary tumors Parotid Gland: 80% of salivary tumors –80% of these are benign Submandibular Gland: 10-15% of tumors Submandibular Gland: 10-15% of tumors –50% of these are benign Sublingual and minor glands: 5-10% of tumors Sublingual and minor glands: 5-10% of tumors –40% are benign

20. Benign Tumors Benign Mixed Tumor (Pleomorphic adenoma) - The most common tumor of the parotid gland Benign Mixed Tumor (Pleomorphic adenoma) - The most common tumor of the parotid gland Warthin's Tumor (papillary cystadenoma lymphomatosum) - Occurs most frequently in the "tail" of the parotid gland of white, middle aged males. Appear "hot" on Tc99 scan. Bilateral lesions commonly occur Warthin's Tumor (papillary cystadenoma lymphomatosum) - Occurs most frequently in the "tail" of the parotid gland of white, middle aged males. Appear "hot" on Tc99 scan. Bilateral lesions commonly occur

21. Malignant Tumors Often asymptomatic, but may show rapid tumor enlargement, pain, trismus, or facial nerve palsy Often asymptomatic, but may show rapid tumor enlargement, pain, trismus, or facial nerve palsy FNA has 95% sensitivity in salivary gland neoplasms. Any patient with a salivary gland mass should undergo FNA FNA has 95% sensitivity in salivary gland neoplasms. Any patient with a salivary gland mass should undergo FNA –Incisional biopsy is contraindicated due to tumor seeding

22. Malignant Tumors Adenoid Cystic Carcinoma - Very lethal even when treated early. Although five-year survivals are quite good, 20 year survival is very poor-15% or less depending on site of origin. Most patients die of pulmonary metastases. This tumor also has a proclivity for perineural spread. Adenoid Cystic Carcinoma - Very lethal even when treated early. Although five-year survivals are quite good, 20 year survival is very poor-15% or less depending on site of origin. Most patients die of pulmonary metastases. This tumor also has a proclivity for perineural spread. Mucoepidermoid Carcinoma - Graded into high grade (very malignant and lethal) to low grade (very curable with surgery alone). The most common parotid tumor seen in childhood. Mucoepidermoid Carcinoma - Graded into high grade (very malignant and lethal) to low grade (very curable with surgery alone). The most common parotid tumor seen in childhood.

23. Malignant Tumors Acinic Cell Carcinoma - Low grade malignancy Acinic Cell Carcinoma - Low grade malignancy Squamous Cell Carcinoma - Very aggressive tumor. Must rule out metastasis from a skin lesion to parotid lymph nodes. Primary parotid lesions tend to metastasize to cervical lymph nodes. Squamous Cell Carcinoma - Very aggressive tumor. Must rule out metastasis from a skin lesion to parotid lymph nodes. Primary parotid lesions tend to metastasize to cervical lymph nodes.

24. Treatment of parotid tumors Superficial parotidectomy for benign tumors Superficial parotidectomy for benign tumors

25. Treatment of parotid tumors Malignant tumors often warrant total parotidectomy Malignant tumors often warrant total parotidectomy Facial nerve is sacraficed only for direct invasion or pre-existing facial nerve paralysis Facial nerve is sacraficed only for direct invasion or pre-existing facial nerve paralysis Squamous cell or high grade mucoepidermoid – may require a neck dissection Squamous cell or high grade mucoepidermoid – may require a neck dissection

26. Treatment of parotid tumors Radiation Radiation –High grade tumors –Close Margins –Recurrent disease –Positive nodes –Unresectable disease No effective chemotherapy No effective chemotherapy

27. Submandibular and Sublingual glands o Complete excisions of the gland and tumor. o If a malignancy is discovered, then a neck dissection and perhaps excision of the floor of mouth may be indicated depending on the tumor type.

28. Minor Salivary Glands The operation depends on the location of the involved gland, but complete excision with a margin of normal tissue is essential. The operation depends on the location of the involved gland, but complete excision with a margin of normal tissue is essential. In the case of adenoidcystic carcinomas, surrounding nerves must be sampled for possible invasion and excised if involved. In the case of adenoidcystic carcinomas, surrounding nerves must be sampled for possible invasion and excised if involved.

29. THE END