DIAGNOSIS AND TREATMENT OPTIONS IN HEAD AND NECK NEOPLASMS EVAN S. BATES, M.D. DEPT. OF OTOLARYNGOLOGY.
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Transcript DIAGNOSIS AND TREATMENT OPTIONS IN HEAD AND NECK NEOPLASMS EVAN S. BATES, M.D. DEPT. OF OTOLARYNGOLOGY.
DIAGNOSIS AND
TREATMENT OPTIONS IN
HEAD AND NECK
NEOPLASMS
EVAN S. BATES, M.D.
DEPT. OF OTOLARYNGOLOGY
NASAL/SINUS TUMORS
Overall incidence: 1:100,000
80% SCCA, 10% ACC/AC
Risk factors: environmental exposure
Diagnosis
CT/MRI, biopsy
Treatment
Surgical resection
Chemotx/XRT
CASE PRESENTATION
This 37 yo male presented with a 4-5 week H/O an
enlarging left neck mass. 3 months earlier he noted
episodes of left nasal congestion with eye discomfort.
PMH: ASD repair 3/96
H/O smoking 1ppd/15 yr., quit 5 yr. go
Exam:
nasal: polypoid mucosa left inf.turbinate
oropharynx: nl.
neck: 6 x 5 cm firm, mid. Cervical mass
EVALUATION
FNAB:
+ for malignant cells
immunostain profile suggests medullary CA
MRI:
large left neck mass, adenopathy in levels 2-4, small
left intraparotid masses. Thyroid nl.
CXR: nl.
Laboratory:
calcitonin 2, CEA <0.7, TSH, LFT’s nl.
DIFFERENTIAL DIAGNOSIS
Lymphoma
Primary salivary neoplasm
mucoepidermoid CA, squamous CA, adenoCA
Thyroid neoplasm
anaplastic CA, medullary CA
Sinus neoplasm
squamous CA, adenoCA
Unknown Head & Neck Primary
SURGICAL MANAGEMENT
Left radical neck
dissection
Left total parotidectomy
SURGICAL FINDINGS
Normal thyroid gland
Multiple parotid cysts
Large left neck mass w/ additional
adenopathy
Frozen section
c/w malignant neoplasm
Permanent section
c/w rhabdomyosarcoma, alveolar type
SURGICAL MANAGEMENT
Left endoscopic turbinectomy, resection
of nasal mass
findings
large polypoid mass on posterior inf. Turbinate
with extension superiorly along lateral nasal wall
to middle meatus
path
rhabdomyosarcoma
RHABDOMYOSARCOMA: MD
ANDERSON EXPERIENCE
5 yr. Survival 44%, 60% w/combined TX.
Poor survival
adult onset of disease
alveolar histology-distant mets
Symptoms:
nasal obstruction (60%), facial pain (41%), facial
swelling (38%), proptosis (35%), epistaxis (27%)
RHABDOMYOSARCOMA:
UCLA EXPERIENCE
Orbit (35%), Maxillary sinus (15%)
35% had CNS extension from sinus/orbit
Histology not a factor in prognosis
Overall survival 34%
Trend toward conventional surgery
followed by intensive chemo/XRT
RHABDOMYOSARCOMA
Most common head&neck tumor in children,
rare in adults
69% advanced @ presentation (Group III,IV)
Ethmoid sinus most common site (46%)
Nodal mets (46%), systemic mets(26%)
Management: chemo/XRT/surgery
7.6% 5 yr. survival
NOSE EXAMINATION
Usually seen in chronic
sinusitis or chronic
allergy patients
Topical corticosteroids of
minimal benefit
Polyps require sugical
excision and biopsy
followed by long term
allergy management
NASAL POLYPS
OROPHARYNGEAL
CARCINOMA
Usually presents with painful oral ulcer
Adult males 50-70 yrs. old
Risk factors: smoking, ETOH
Majority of tumors SCCA, lymphoma
Management:
Surgery/XRT
XRT/CHemotx
TONSILLAR CARCINOMA
20-30% present with neck metastases
Evaluation with CT/MRI, Chest CT, PET scan,
LFT’s
Management must include neck disease
Stage I survival 80-90%, Stage IV survival 2540%
Treatment standard involves surgery/XRT
TONGUE NEOPLASMS
3% of all CA in US, 50% of CA in India,
3rd most common malignancy in France
>90% SCCA, associated with tobacco
use, ETOH
Survival rate decreased with lymphatic
involvement
Treatment focused on surgery/XRT
Reconstruction of prime importance
TONGUE CARCINOMA
Tongue lesions can be resected primarily
due to tongue redundancy
Primary closure vs. local flap
XRT for incomplete resection, T2 or
greater lesions or nodal disease
TONGUE MASS
Neurofibroma
Mucosal covered mass rather than
ulcerated lesion
Surgical resection alone is sufficient
NECK EXAMINATION
NECK MASSES
KEY TO DIAGNOSIS IS HISTORY
TIME COURSE OF MASS
PAINFUL/TENDER
RECENT
INFECTIONS/TRAUMA
SMOKER?
PHYSICAL EXAM
LOCATION OF MASS
FIRM/CYSTIC/TENDER/MULTIP
LE MASSES
NECK MASSES
IF YOU SUSPECT INFECTION,
TREAT WITH 1 COURSE OF
ANTIBIOTICS
IF NO RESOLUTION, REFER TO ENT
EVALUATION
HEAD & NECK EXAM
FNA-B
CT/MRI
NECK EXAMINATION
THYROID MASS
Large thyroid mass
suspicious for
malignancy
FNA-B important
Surgical resection with
CN X monitor
Post-operative therapy
dependent on path
LIP CARCINOMA
Uncommon site for
oral carcinoma
Usually managed
with wide local
excision
Frequently seen in
pipe smokers
HOARSENESS
MANAGEMENT:
REFER TO ENT IF PROLONGED OR
DIAGNOSIS UNCERTAIN
INDIRECT LARYNGOSCOPY
BE SUSPICIOUS OF MALIGNANCY
IN SMOKERS AT ANY AGE
LARYNGEAL CARCINOMA
Usually seen in
smokers
Extremely hoarse voice
for several weeks
May have referred
otalgia
Obviously needs
laryngoscopy/biopsy
LARYNGEAL CARCINOMA
Treatment goals shifted to larynx preservation
based on 1992 VA study
11,000 new cases annually, >90% have
smoking exposure
Induction chemotx/XRT preserves larynx in
64% patients
XRT for T1/T2 lesions
5 yr. Survival 70-80% for T3< lesions, 40% for
T4 lesions
LARYNX EVALUATION
VOCAL CORD NODULE
Usually a gravelly/hoarse voice
History of voice
overuse/singers
Voice rest may help
Often associated with GERD
ENT eval. for laryngoscopy
HOARSENESS
ASSOCIATED WITH URI
SELF-LIMITED
RESOLVES IN 7-21 DAYS
PROLONGED RESOLUTION IN
SMOKERS
MANAGEMENT
ANTIBIOTICS (S. AUREUS)
HUMIDIFICATION
STEROIDS
HOARSENESS
CHRONIC HOARSENESS
VOCAL OVERUSE
VOCAL FOLD POLYPS
GERD
PRESBYLARYNGIS
ACUTE HOARSENESS
IF ASSOCIATED WITH NECK
TRAUMA--ER