HEAD AND NECK CANCER REVIEW

1. DRVIPINV NAIR
SENIOR RESIDENT
PLASTIC SURGERY PGIMER

2. Tumors in several
areas above the
collar bone.

3.  Oral Cancer  Laryngeal
Cancer
 Nasopharyngeal
Cancer

4. CANCERSOF HEAD & NECK
Squamous cell carcinoma Non - Squamous cell carcinoma
1. Oral cavity & oropharynx
2. Larynx & hypophaynx
3. Nasopharynx
4. Nasal cavity
5. Paranasal sinuses
1. Thyroid
2. Salivary glands
3. Sarcomas
- soft tissue
- hard tissue

5. Surface Epithelium
1- Squamous cell Carcinoma
▪ Undifferentiated carcinoma
▪ Differentiated carcinoma
▪ Adenoid squamous carcinoma
▪ Verrucous carcinoma
2- Basal cell carcinoma
3- Malignant Melanoma

6. Glandular epithelium
1- Adenocarcinoma
2- Mucoepidermoid
carcinoma
3- Adenoid cystic
carcinoma
4- Acinic cell carcinoma
5- Undifferentiated
carcinoma

7. Mesenchymal tissues
Sarcoma
 Fibrosarcoma
 Rhadomyosarcoma
 Osteogenic sarcoma
 Chondrosarcoma
 Neurogenic sarcoma
 Angiosarcoma
 Synovial cell sarcoma
Hodgkin’s & non-Hodgkin’s lymphomas
Plasmacytoma & multiple myeloma
Metastatic carcinoma, sarcoma

10. 7 Categories:
 1) Adenomas
 2) Carcinomas
 3) Malignant melanoma
 4) Non epithelial tumours
 5) Secondary tumour
 6) Undifferentiated tumours
 7)Tumour like

11. 1) Acinic cell Ca.
2) Mucoepidermoid Ca.
3) Adenoid cystic Ca.
4) Adenocarcinoma
5) Polymorphous low-grade adenocarcinoma
6) Papillary cystadeno Ca
7) Squamous cell carcinoma
8) Mucinous adenocarcinoma
9) Carcinoma ex pleomorphic adenoma;
10) Malignant mixed tumour
11) Undifferentiated ca

12. Squamous cell carcinomas.
L. Licitra, E. Felip. Squamous cell carcinoma of the head and neck: ESMO Clinical
Recommendations for diagnosis, treatment and follow-up. Ann Oncol . 2009; 20 (4):iv121-iv122.
doi: 10.1093/annonc/mdp149

15.  Leading cause of death worldwide
 7.6 million deaths (around 13% of all deaths) in 2016
GLOBOCAN 2013 (IARC) Section of Cancer Information (8/12/2013).

16. - Wide variations
France (supraglottic, oral cancers)
Hong Kong (nasopharyngeal cancers)
India (oral cancers)

19. “Genes load the gun.
Lifestyle pulls the trigger”
Dr. Elliot Joslin
Lifestyle Factors

20. Genetic factors
Endocrinal
disturbances
Immunologic
factors
Infections
Tobacco
Occupational
exposuresRadiation
Dental factors
Nutritional
factors
Inflammatory
causes
Alcohol

21. Smoking
 90% cases
 Contains 30 known
carcinogens
 Polycyclic aromatic
hydrocarbons
 Nitrosamines
 Alcohol adds up in pathology
The areas of oral cavity which is bathed
with saliva, are most common sites to
be involved.
Ex : Oropharynx
Crypts of tonsil,
Glossotonsillar sulcus,
Tongue
Soft palate
Posterior pharyngeal wall.

22. Black / dark
Air cured
Blend & blond
Flute cured
More carcinogenic

23. Smokeless :
 Most common in Indian suncontinent
Bidi Chutta
khaini paan

24.  Synergistic action with tobacco.
 Mostly associated with cancer of
 Lateral border of tongue
 Glossotonsillar sulci
 Pharyngoepiglotic fold

25.  Acts as an solvent
 Up regulation of cyt p450
 Decreased activity of DNA
repair enzymes
 Impairment of immunity
 Decrease resistance to cancer

26. Beer – Nitrosomethylamine
Wine – tannin
Light liquor – ester,
acetaldehyde
Different alcoholic beverages have
different carcinogenic contents :
Dark liquor – ester,
acetaldehyde

27.  Sharp tooth
Poor Oral hygiene

28.  Patients with ill fitting
dentures

29.  Alcohol containing
mouth washes
(to mask the smell of
tobacco/alcohol)

31.  Wood dust
Coal
Chemical

32.  Wood dust
H2so4 & HCl exposure in battery plants
Asbestos exposure
Ni & mustard gas

33.  Ni alloy dust

34.  Urethane
Polycyclic hydrocarbons Ethylene derivatives

35. 30-100% verrucous
carcinoma
50% cases of NPC have
HPV
5% cases of H&E cancers have HIV
inhections (kaposi sarcoma)
Mostly associated with
nasopharyngeal
cacinoma
42 % oral cancer & all smokers
with & without cancer,have
higher HSV antibody titre.

36. Carcinogenic nitrosamine in
high salted fish (NPC)
Diet low in iodine : carcinoma of thyroid gland

37. Anti-oxydants
Vit A , C, E

38. GERD
Risk factor in 36-54 % cases
of laryngeal / pharyngeal
cancer.

39.  Fanconi’s anemia
 Bloom syndrome
 Ataxia
 Telegiactasis
Autosomal recessive disorder
with increased chromosomal
fragility are associated with
oral cavity & pharyngeal
carcinoma.
 Li- Fraumeni syndrome : autosomal dominant condition
mutation of p53 gene
 Fanconi’s anemia
 Bloom syndrome
 Ataxia
 Telegiactasis
Autosomal recessive disorder
with increased chromosomal
fragility are associated with
oral cavity & pharyngeal
carcinoma.

41.  Early menarchy
 Nulliparity
 Older age at full term pregnancy
 Log term Oral contraceptive
Increased risk for salivary gland
carcinomas
Decreased risk for salivary
gland carcinomas

44. Mild / thin leukoplakia
Homogenous / thick leukoplakia
Ulcerated leukoplakia
Nodular/ speckled leukoplakia
Verrucous leukoplakia
Erythroleukoplakia
Malignant potential : 0.3 – 10 %

45. Homogenous & smooth Erythroplakia
Granular Erythroplakia
Erythroleokoplakia
17TIMES MORE MALIGNANT POTENTIAL
THAN LEUKOPLAKIA

46. Stomatitis nicotina Snuff dipper's lesion
Cigarette smoker’s lip lesion

47. -Mostly involve skin
-May involve mucosa
- SCC in situ – Bowen Disease
Carcinoma insitu

48.  A cutaneous premalignant lesion
 Gives – SAND PAPER APPEARANCE
 KERATIN HORN may present
Actinic keratosis

49. Malignant potential : 0.2 – 0.5 % in INDIAOSMF
Oral submucous fibrosis

50. Wickham’s striae
are diagnostic
Malignant potential : 0.4 – 12.3 %
OLP (Oral lichen planus)

51. It presents a chronic multiple oral
mucosal ulcers, which occurs when there
is extreme degeneration of basal cell
layer of epithelium.
Malignant potential : 1 – 15 %
Erosive lichen planus

53. Lupus Erythmatosis

55.  Unfortunately patients are most often identified only after
development of symptoms at advanced stages of disease.

56.  Discomfort
 Most common
symptom
 85 %

57.  Hoarseness
 Persistent sore throat

58.  Epistaxis  Nasal obstruction

59.  Erythroplasia  Referred otalgia

60. SEROUS OTITIS MEDIA NECK MASS

61. NON-HEALING ULCER SUBMUCOSAL MASS

62.  Dysphagia

63. UNDEFINEDWEIGHT LOSS

64. Patient remains
asymptomatic
for LONGTIME
Patient
procrastination
in seeking
medical
attention
Physician delay
in diagnosis

65. Staging is the process subdivision of cases of cancer
into same groups in which behavior will be similar.

71. Clinical classification / pretreatment Clinical
classification (cTNM)
CLASSIFICATIONS

72. Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor ≤ 2 cm in greatest dimension
T2 Tumor > 2 cm but ≤ 4 cm in greatest dimension
T3 Tumor > 4 cm in greatest dimension
T4a Moderately advanced local disease
T4b Very advanced local disease
NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. V 2. 2011.

73. Regional lymph nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node ≤ 3 cm in
greatest dimension
N2 Metastasis in a single ipsilateral lymph node > 3 cm but
≤ 6 cm in greatest dimension; or in multiple ipsilateral
lymph nodes, none > 6 cm in greatest dimension; or in
bilateral or contralateral lymph nodes, none > 6 cm in
greatest dimension
N2a Metastasis in a single ipsilateral lymph node > 3 cm but
≤ 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none > 6
cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes,
none > 6 cm in greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest
dimension

74. Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis

75. Anatomic Stage/Prognostic Groups*
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3
T1
T2
T3
N0
N1
N1
N1
M0
M0
M0
M0
Stage IVA T4a
T4a
T1
T2
T3
T4a
N0
N1
N2
N2
N2
N2
M0
M0
M0
M0
M0
M0
Stage IVB Any T
T4b
N3
Any N
M0
M0
Stage IVC Any T Any N M1

76.  Gx : Grade Of Differentiation Can Not Be Assessed
 G1 :Well Differentiated
 G2 : Moderately Differentiated
 G3 : Poorly Differentiated
 G4 : Undifferentiated
Pathological classification / postsurgical
H/P classification (pTNM)

77.  Retreatment classification (rTNM)
Rx : Grade Of Differentiation Can Not Be Assessed
R0 : No residual tumor is present
R1 : microscopic residual tumor
R2 : macroscopic residual tumor

78. Autopsy classification (aTNM)
Other descriptors
“m” suffix (> 1 primary at single site)

80. • Surgery
• Radiation
Early stages
• Chemoradiation or Surgery
• Followed by radiation and
chemotherapy
Advanced stages
•Radiation and chemotherapyVery advanced
cases

83.  TheTMN 8th edition is being published in December 2016.
Comes into effect on January 1, 2017.

84. • Oropharynx
• Unknown primary cervical neck lymph nodes

85. • Head and Neck Nodes
• Nasopharynx
• Thyroid

86. • Clarify ITC
• EssentialTNM

87.  Single tumour cells or small clusters of cells not more than
0.2 mm in greatest extent that can be detected by routine
H and E stains or immunohistochemistry.

88.  Record of cases in Cancer Registry in all
countries
 And adding report to NCCN registry

89. For all sites there are separate classifications for clinical and
pathological neck nodes
There is a new classification for p16 positive oropharyngeal
cancers.Tumours that have p16 immunohistochemistry
overexpression.

90. Classification for nasopharyngeal cancers and
thyroid cancers has been modified
New classification for squamous cell carcinoma
of the skin in the head and neck region
New classification for cervical nodal involvement
with unknown primary

91.  Pathological
 N1, N2a, N2b and N2c unchanged
other than specify without
extranodal extension
• pN3a Metastasis in a lymph
node more than 6 cm in
greatest dimension without
extranodal extension
• pN3b Metastasis in a lymph
node more than 3 cm in
greatest dimension with extranodal
extension or, multiple
ipsilateral, or any contralateral or
bilateral node(s) with extranodal
extension
Clinical
N1, N2a, N2b and N2c unchanged
other than specify without extranodal
extension
• N3a Metastasis in a lymph node
more than 6 cm in greatest
dimension without extranodal extension
• N3b Metastasis in a single or
multiple lymph nodes with clinical
extranodal extension*
*The presence of skin involvement or soft tissue
invasion with deep fixation/tethering to underlying
muscle or adjacent structures or clinical signs of
nerve involvement is classified as clinical extra nodal
extension

92. Clinical and Pathological T categories
• T1 Tumour 2 cm or less in greatest dimension
• T2 Tumour more than 2 cm but not more than 4 cm
• T3 Tumour more than 4 cm in or extension to lingual surface of
epiglottis
• T4 Tumour invades any of the following: larynx, deep/ extrinsic
muscle of tongue (genioglossus, hyoglossus, palatoglossus, and
styloglossus), medial pterygoid, hard palate, mandible*,
lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull
base; or encases carotid artery

93. Clinical N categories
N0 No regional lymph node
metastasis
N1 Unilateral metastasis, in
lymph node(s), all 6 cm or less
N2 Contralateral or bilateral
metastasis in lymph
node(s), all 6 cm or less in greatest
dimension
N3 Metastasis in lymph node(s)
greater than 6 cm in
dimension
Pathological N categories
pN0 No regional lymph node
metastasis
pN1 Metastasis in 1 to 4 lymph
node(s)
pN2 Metastasis in 5 or more
lymph node(s)

94. T categories
T1 Unchanged
T2 Tumour with extension to
parapharyngeal space and/or infiltration of
the medial pterygoid, lateral pterygoid,
and/or prevertebral muscles
T3 Tumour invades bony structures of
skull base cervical vertebra, pterygoid
structures, and/or paranasal sinuses
T4 Tumour with intracranial extension
and/or involvement of cranial nerves,
hypopharynx, orbit, parotid gland and/or
infiltration beyond the lateral surface of the
lateral pterygoid muscle
N Categories
N1 Unilateral metastasis, in cervical lymph
node(s), and/or unilateral or bilateral
metastasis in retropharyn-geal lymph
nodes, 6 cm or less ,above the caudal border
of cricoid cartilage
N2 Bilateral metastasis in cervical lymph
node(s), 6 cm or less above the caudal
border of cricoid cartilage
N3 Metastasis in cervical lymph node(s)
greater than 6 cm in dimension and/or
extension below the caudal border of cricoid
cartilage

95.  If EBV positive stage as per
nasopharyngeal carcinomas
 If p16 positive stage as per p16
positive oropharynx carcinomas
 If EBV and p16 negative clinical and
 pathological node definitions are as
 above
Stage III T0 N1 M0
Stage IVA T0 N2 M0
Stage IVB T0 N3 M0
Stage IVC T0 N1, N2, N3 M1

96. The definition ofT3 has been revised for papillary
and follicular and medullary carcinomas
T3a Tumour more than 4 cm in greatest
dimension, limited to the thyroid
T3b Tumor of any size with gross
extrathyroidal extension invading only
strap muscles (sternohyoid, sternothyroid,
or omohyoid muscles)
Stage < 55 years old
Stage I AnyT Any N M0
Stage II AnyT Any N M1
Stage >55 years old
Stage I T1a,T1b,T2 N0 M0
Stage II T3 N0 M0
T1,T2,T3 N1 M0
Stage III T4a Any N M0
Stage IVA T4b Any N M0
Stage IVB AnyT Any N M1
The age for a poor prognosis has changed
from 45 years to 55 years

98. Normal
HPV
9p,3p
Dysplasia
CISHNSCC
p53
13q,17p
? 6p
14q,8p
11q,4q

99.  Ultrasonography and Guided FNAC
Real time
Inexpensive
Quicker but operator dependent
Doppler can show flow characteristics

100. CT Scan with 3 D views

103. Residual / recurrent locoregional disease
Detection of occult primaries in MUO
Occult metastatic disease in the neck
Synchronous primaries or metastasis
18FDG-PET

104. Oral cavity: Pattern of Mandibular
invasion
Mandible Preservation

105. Larynx: Endoscopic Laser Excision
Conservative laryngectomy
Primary voice rehabilitation

106. PNS Tumors: Endoscopic Sinus Surgery
Cranio-facial Excision

107. Alt. Fractionation-
 Accelerated
 Hyperfractionation .

108. Radiation beams to match the shape of the tumor

109. Gives radiation therapists the ability to "sculpt"
the edges of a tumor, minimizing the damage
to adjacent healthy tissue

110.  Stereotactic/ Fr. Stereotactic
Radiothearpy

111.  Neutron Beam/Charged Particle RT
 Intraoperative Radiotherapy

112.  Palliation
 Curative intent- Small
primary tumor
 Second primary/
Recurrent tumor
 Premalignant lesions

113.  Possible Roles
• Reversal of oral pre-cancerous lesions
• Primary chemoprevention in high-risk
 Phamacological Agents
• Beta Carotene
• Retinoids- 13cRA,Vitamin A
• Retinamides
 a-tocopherol

115. Augmentation therapy
Immunotherapy:
Cytokine gene transfer- IL-2,IL-12, IFN- g
Vaccination Tumor specific antigen
Co-stimulator molecule
Foreign antigen
Chemotherapy: HSV TK
Drug sensitization / Drug resistance

116. Gene replacement
Replace tumor suppressor gene- p53
Inhibit an oncogene- Antisense c DNA
Adjuvant Therapy-
Post CT / RT/ Surgery

119.  Provides 3D road map.
 Size
 and volume are restored
accurately.
 Advantages
 Accuracy
 Least trauma,
 Shorter surgery
 Reduced complications
 Fewer recurrence
 Excellent success rate

120. Mandibular Reconstruction
 All young patients
 Cenral mandibular defects
Better cosmesis
Prevents mandibular deviation
Teeth can be implanted

121. Single fibular flap (FFOCF) is adequate for most
of the composite oromandibular defects.
Skin paddles divided
on septocutaneous
perforators

122.  Reconstruction plate
 Very high risk
 Poor prognosis patients
 Spacer for definitive reconstruction at later date.

123.  Maxilla is six-dimensional hollow bone
 Loss
 Aesthetic disruption
 Affects eating
 Swallowing
 Speech .

124. Assessed in horizontal and vertical dimensions.
Reconstructive options available are
from prosthesis to free tissue transfer

125. Isolated palatal defect
 Obturator
 Local flap
 Free tissue flap
Larger defects
reconstruction
•Free fibula
osteocutaneous flap
•Prelaminated Free ALT
•Free Rectus abdominis
myocutaneous flap.
To prevent contour deformity due to sagging of heavy
flap anchoring flap to zygoma is recommended.

126.  To evaluate exact site,
size and shape of the
defect preoperatively
by using 3D imaging of
the area involved.
Virtual mandibular resections are done to
prepare customized plate or implant.

127.  Similar technique used
to develop a template
for fibular bone
osteotomy.
 Guides in deciding
which part and surface
of fibula is best for
dental implant.
Disadvantages
 Does not decrease
operative time
 Cost
 Facility may not be
available.

129.  Reach inaccessible
region easily.
 Surgeon has
comfortable sitting
position at console.
 With 3D, endoscopic,
microscopic image and
sensitive controls
desired procedure can be
done even from a
remote place.
Resections and
reconstruction of
tumours at base of
tongue and larynx,
avoiding mandibulotomy

130.  With trans-axillary
approach
 Thyroid
 Para thyroid adenoma
 Neck lymph node can
be operated
without giving scar on
the neck

131. Tissues can be regenerated,
replaced or repaired for
specific purposes.
 Three components decides
success of tissue engineering:
 Scaffold
 Signalling molecule
 Cells

132.  One flap with similar
colour, texture,
thickness and
composition
 Patient’s face is
removed and
replaced with
composite allograft.
 30 cases have been
reported in the
literature.

133.  Transformed lives of
nearly all surviving
recipients.
 They have regained
their ability to eat,
drink, speak, smell,
smile and blink.
 Lifelong
immunosuppressant
therapy

134.  Success in head and
neck cancer treatment
requires
 Knowledge
 Careful preop planning
 Goal
 Return the patient to as
close as possible to
preop status

135.  Reconstructive surgery is an essential part of
head and neck cancer surgery
 Improves the form and function of survivors
 Improves quality of life.
 However other adjuvents as described in this
presentation is as much helpful for good
patient recovery and should be kept in mind
during treatment planning .

142. “We unite the cancer community to reduce the
global cancer burden, to promote greater equity,
and to integrate cancer control into the world
health and development agenda.”
December 2016

143.  American Cancer Society. Cancer Facts & Figures 2017. Atlanta, Ga:American
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 NationalCancer Institute. Physician DataQuery (PDQ). OropharyngealCancer
Treatment. 12/12/2013. Accessed at
www.cancer.gov/cancertopics/pdq/treatment/oropharyngeal/HealthProfessional
on June 5, 2014
 NationalComprehensive Cancer Network (NCCN). NCCN Clinical Practice
Guidelines in Oncology: Head and Neck Cancers.V.2.2014. Accessed at
www.nccn.org on June 5, 2014

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145. Thanks