Head & Neck Ca Lecture'08 Edited

MALIGNANT TUMORS of the HEAD and NECK Ramon P. Ramos III M.D, DPBOHNS, FPSO-HNS

PARANASAL SINUS MALIGNANCY Uncommon in the general population Most common malignancy is SCCA <1:200,000 per year. Initially mimics benign disease Diagnosis is evident only after advanced stage is reached, thus the relative poor prognosis

PARANASAL SINUS ANATOMY

SYMPTOMS OF PARANASAL SINUS CANCER Diplopia, vision loss Epiphora Facial swelling and maloclussion Trismus Neck mass Hearing loss Facial numbness

PHYSICAL FINDINGS OF PNS MALIGNANCY NASAL, FACIAL OR INTRA ORAL MASS PROPTOSIS CRANIAL NERVE DEFICITS

DIAGNOSTIC ASSESMENT THOROUGH EXAMINATION IMAGING STUDIES CT scan (radiographs unnecessary) angiography ultrasound PET scan MRI BIOPSY

PARANASAL SINUS LYMPHATICS by:Ohngen Lateral retropharyngeal LN receive most of the lymph vessels. Drain to the deep jugular chain at the carotid bi-furcaton

PATTERNS OF SPREAD

OHNGREN’S LINE

DISTRIBUTION OF PRIMARY SITES of NASAL and PNS TUMORS      

Overlapping sites Nasal cavity Maxilla Ethmoid Frontal sphenoid

HISTOLOGIC DISTRIBUTION of MALIGNANT TUMORS of NASAL CAVITY and PNS  SCCA  Others  Adeno. CA  Adenoid cystic CA  Mucoepideroid CA  Melanoma  Esthisioneuroblastoma note: 75% of PNS and nasal cavity tumors are malignant. 25% is benign

STAGING CRITERIA: PRIMARY TUMOR (T)

COMPLICATIONS Increase significantly when surgery breaches the intracranial space. When high dose irradiation is delivered intracranially. Examples: Meningitis, brain abscess, CSF leak, post op wound bleeding, cataracts, optic neuritis, blindness, osteo-radionecrosis and hypopituitarism

MANAGEMENT SURGERY COMBINED SURGERY and IRRADIATION RADIOTHERAPY CHEMORADIATION THERAPY

SURGICAL OPTIONS External ethmoidectomy  Most limited OR  For benign tumors of ethmoid region, biopsy, drainage.

Inferior medial maxillectomy Resection of medial wall of antrum and inferior turbinate. Often used for inverting papilloma Medial maxillectomy larger benign or intermediate tumors of the lateral nasal wall with ext. to orbit, ant. Cranial fossa, lateral maxilla or alveolus

Radical maxillectomy standard operation for advanced CA of the maxilla. Craniofacial frontoethmoidectomy en bloc resection for tumors of ethmoid and frontal regions. Dural resection when necessary.

Extended craniofacial resection extensive tumors if the skull base, pterygoid plates.

CARCINOMA of the ORAL CAVITY and PHARYNX Major therapeutic challenge due to the poor prognosis of advanced disease, assoc medical problems and adverse effects of treatment on oral and pharyngeal function. Common in parts of India, China and Asia. Incidence incrases with age. Commonly seen at 6th-7th decade.

ETIOLOGIC FACTORS Tobacco smoking Smokeless tobacco use Betel nut chewing Heavy alcohol consumption Reverse smoking Poor oral hygiene Mechanical irritation HPV Syphilis Erosive lichen planus Oral sub mucus fibrosis Sun light exposure (lower lip) note: there is approx. 50% 5 year survival for all oral pharyngeal carcinoma patients

and

PATHOLOGY 90% of all malignant tumors of oral cavity and pharynx are SCCAs. Other tumor types - minor salivary gland tumors, sarcomas, lymphomas and melanoma. SCCA morphologic types   

Ulcerative type – most common Infiltrative type – commonly in the tongue Exophytic type – least common form

Microscopically graded   

Well differentiated Moderately well differentiated Poorly differentiated

Note: degree of diff. does not appear to have strong prognostic significance except in NPCA.

Leukoplakia – white patch of mucosa. Appears to be pre-malignant. Histologically shows epithelial hyperplasia in 80%. It may harbor dysplasia, Cis or even invasive CA. Should be biopsied. Erythroplakia – rare red velvety plaque like lesion. Higher rislk of malignancy than leukoplakia.

ORAL CAVITY Lips Buccal mucosa Lower alveolar ridge Upeer alveolar ridge Retromolar trigone Floor of the louth Hard palate Anterior 2/3 of the tongue

PHARYNX

GENERAL PRINCIPLES and EVALUATION Patients with oral cavity and pharynx CA have co existing medical illnesses Heavy alcohol intake and may have liver disease. COPD is common. Nutritional deficiency with a big tumor burden. Multi disciplinary approach ; radiation oncology, medical oncology, dentistry, social services, nutrition, speech pathologist and nursing services.

EVALUATION: thorough history and examination. biopsy of the primary. FNAB of LN. RADIOLOGY: CT Scan MRI Radiography ENDOSCOPY: Under GA for accurate mapping. Laryngoscopoy, esophagoscopy, bronchoscopy. 5%-10% incidence of synchronous malignancy.

GENERAL MANAGEMENT Most patients are treated with either surgery and radiation or in combination. chemotherapy alone has not shown to be effective. Its role in adjunctive therapy of unresectable CA is uncertain. In general T1-T2 tumors of the oral cavity and pharynx (except NP) can be treated effectively with RT or surgery only. Combination treatment is preferred for bulky tumors T3T4 tumors. Post op RT is preferred. Pre op RT makes dissection difficult and makes resection margins unclear. CT and RT for organ preservation may be undertaken.

Small lesion of the oral cavity – surgery is preferred to avoid SE of RT. Small lesions of the soft palate and hypopharynx RT is preferred to avoid functional problems. Tracheostomy may be needed in large resections to protect the airway.

NECK DISSECTION    

 

Clinical neck mets in most cases require surgery. N1 necks may be treated with RT alone Most would recommend ND for clinically pos. nodes Combination therapy indicated in multiple and extracapsular nodal extension. MRND in N1 and selected N2 dis. RND for advanced dis. (N2,N3)

Incidence of occult metastasis for oral cavity oral tongue – 24% floor of the mouth – 30% buccal mucosa – 9% lower alveolar ridge – 19% Incidence of occult metastasis for pharyngeal sites pyriform sinus – 38% base of the tongue – 22% posterior pharyngeal wall – 0%

Occult neck metastasis (No) can be equally managed effectively by either RT or ND Arguments of elective ND:  

  

High incidence of occult dis. in the neck Need for surgical violation of the neck for treatment. Poor ff-up Obese, muscular neck (poor surveillance) Recognition of advance dis. at time of treatment.

Arguments against elective neck dissection: 

  

Morbidity and deformity of ND, spinal acc. nerve damage. Unnecessary surgery RT effectively controls occult mets. Survival has not been shown worse if one observes for occult dis. to be palpable,

CARCINOMA OF THE LIPS 25%-30% oral carcinomas 98-99% SCCA 95% lower lip involved 5% upper lip Basal cell CA most commo CA of the upper lip (chronic sun expoxure) Usually in patients 50-70 yrs old. Male>females (95%) Neck mets. is infrequent (<10%) Upper lip CAs mets. to pre auricular, sub mandibular and sub mental LN. Lower lips CAs mets. to submandibular and submental LN. more prone to bilat. Mets. Surgical excision and RT for small lesions. Local flaps for larger lesions 5 year survival stage I-II 90%. StageIII-IV with nodal dis.<50%

BUCCAL MUCOSA CANCER 5% oral cavity CAs 7th decade of life with men>women Frequently with tobacco and betel nut chewers.most common in the lower third molar area. Trismus noted if with masseter or pterygoid involvement. Cervical mets in 50% of patients to the submandibula and upper deep cervical LN. Small lesion treated with surgery or radiation. Advanced lesions treated with combined therapy. Cervical mets indicates poor prognosis. 5 year survival rate 25% 5 year survival rates for stage I-II-III-IV are 75%-65%30%-20% respectively.

FLOOR OF THE MOUTH CANCER 10-15% of oral cavity CAs. Occurs more in males with ave. age of 60 yrs. Cervical mets is common and present in 50% of cases. (sub mandibular LN) Propensity of Mandibular involvement in advance dis. is not unusual. CT Scan used to det. Mandibular involvement (marginal vs segmental mandibulectomy) Early (T1-T2) lesions may be effectively treated with surgery or RT. Larger lesions combined therapy is recommended. Small lesions may be excised and may be closed primarily, skin grafted or left to heal. Regional flaps are used for big defects.(platysma, nasolabial) 5 year survival rates for Stage I-II-III-IV is approx. 90%-80%-65%30% respectively.

ALVEOLAR RIDGE CANCER 10% of oral cavity CAs. With mandibular involvement more common than maxilla. (pre molar, molar regions) Bone invasion 50%.Usually via an edentulous area, some via inf. alveolar nerve. CT Scan, panorex etc. help determine bony invasion (sinus, palate, mandible) CA of the lower alveolus has a > metastatic potential as compared to the upper alveolus. (sub mandibular LN, deep cervical LN). 30% incidence of neck mets. Over all 5 year survival 65%. <35% if with neck mets. Marginal, segmental mandibulectomy. Maxillectomy, dental prostheses. Combined treatment for advance dis.

RETRO MOLAR TRIGONE CANCER Affect primarily elderly males (tobacco and alcohol abuser) Commonly involve ant. tonsillar pillar, lower alveolar ridge, buccal mucosa, floor of the mouth and soft palate. Trismus – pterygoid muscles involved Most present with advance dis. 50% have neck mets. (upper deep cervical LN) Radiation or surgery for early lesions. Advance lesions combination therapy. Survival rates is equal to that of the alveolar ridge CAs.

CARCINOMA of the HARD PALATE Rare. Salivary malignancy occur as frequently as SCCA. Predominant in older males, smoker. Higher incidence with reverse smokers. CT Scan, radiographs determine bony involvement and extension to nasal cavity , PNS. 30% present with neck mets. (sub mandibular and upper cervical LNs.) Surgery (maxillectomy, obturator, dental prosthesis) 5 year survival in SCCAs, approx. 40-60%.

CARCINOMA OF THE ORAL TONGUE 2nd most common site for oral cancer. (20%) Can be highly aggressive. Male predominance and occurs at 6th-7th decade of life. Tobacco, alcohol, poor oral hygiene, syphilis, Plummer-Vinson synd. 50% occur at the lateral border of the mid tongue. 40% of cases will have neck mets. 40% of patients will occult mets. Bilateral spread occurs frequently. Surgery (partial glossectomy via mandibulotomy, mandibulectomy, composite flap reconstruction) Radiation for small lesions (xerostomia, long treatment) Combination therapy for advance disease. 5 yr survival stage I-II is 75%; stage III-IV 40%.

CANCER OF THE OROPHARYNX 95% SCCAs. Male predomince at 4th-5th decade of life. Poor cure rates due to advance disease at time of recognition and frequency of mets. (sub mucosal, early lymphatic spread) occurence of regional mets. 40% soft palate, 70% base of the tongue, 30% will have bilat. spread. Upper deep cervical chain, jugulo digastric nodes, retropharyngeal nodes and posterior triangle nodes often involved. Tonsil and tonsillar fossa most commonly involved. Radiation for early lesions (T1-T2) to include neck due high incidence of occult mets. T3-T4 lesions have poor prognosis. Combination therapy (surgeryglossectomy, laryngectomy,reconstruction & RTx) or organ preservation techniques. (RTx & CTx) Complications of chronic aspiration, swallowing problems, speech. Survival rates stage I-II 80%. Stage III – 50%.

CANCER OF THE HYPOPHARYNX 95% SCCAs. Etio. Etiologic cause tobacco, alcohol, GERD* Commonly affect males 6th-8th decade. Pyriform sinus most commonly involved in 70% of cases, post. cricoid and PPW involved in 15% of cases repectively. Symptoms appear late in the disease. (throat pain, referred otalgia, dysphagia, neck mass) Incidence of neck mets is 75% for the pyriform sinus, 40% post cricoid lesions, 60% PPW. High rate of occult mets.(depp cervical nodes, jugulo digastric nodes, retropharyngeal, para tracheal, post. Triangle nodes)

T1-T2 lesions usually treated with RTx. Partial laryngopharyngectomy is suitable (contr indicated if pyriform apex and post cricoid area is involved) Advance T3-T4 lesions combination therapy (total laryngectomy, pharyngectomy, esophagectomy) Distant mets occur in 10-25% of patients. Reconstruction with myocutaneous pedicled flaps, vascular free flaps, jejunum free flap, gastric pull up. 20% of gastric pull up patients will have occult esophageal CA. Over all 5 yr survival 40%

Staging of Hypopharyngeal Cancer

MALIGNANT TUMORS of the NASOPHARYNX

NPCA epidemiology Rare in the west Endemic in the far east. Highest incidence Guangdong Province of Southern China 15-50:100,000 Highest incidence in HK and Singaporean Chinese. Incidence 1:100,000 in most countries.

Genetic pre disposition. Implicated env. Factors nitrosamines from salted fish polycyclic hydrocarbons chronic sinusitis poor hygiene nickel esposure

NPCA is assoc. with EBV. High levels of the anti body to the virus often identified. Peak incidence age 45-55.

NPCA Pathology WHO type 1 – keratinizing squamous ca. graded into well, moderately or poorly differentiated. 25% of NPCAs. WHO type 2 – non keratinizing ca. transitional cell ca. 12% of NPCAs. WHO type 3 – undifferentiated ca. lymphoepithelioma, anaplastic ca, spindle cell and clear cell ca. 63% of NPCAs.

SIGNS and SYMPTOMS Neck mass – 60% Aural fullness – 40% Hearing loss – 37% Epistaxis – 30% Nasal obstruction – 29% Head pain – 16% Otalgia – 14% Neck pain – 13% Weight loss – 10% Diplopia – 8%

CLINICAL EVALUATION High index of suspicion Endoscopy Biopsy Serology – high anti bodies to EBV antigens are tumor markers. >IgA-anti-VCA titer is highly sensitive and > IgA-anti-EA is highly specific. For early dis. Detection. MRI imaging of choice (soft tissue) CT better for bone involvement, LN. compliments MRI.

TREATMENT Initial treatment for all forms is radiation to the primary and both sides of the neck. Chemo. And radiation – for distant mets. Better over all survival and disease free state in advance disease. Neck dissection – for persistent neck disease with control of the primary.

STAGING No universally accepted staging classification for NPCA. American Joint Committee for Cancer Union Internationale Contre le Cancer Ho System

AJCC Staging Nasopharynx: T1 – confined to NP T2 – tumor extends to soft tissues of orophaynx and or nasal fossa T2a – no pararpharyngeal (PP) extension T2b – with PP extension T3 – invades bony structures and/or PNS T4 – intracranial extension/cranial nerves/infra temporal fossa/hypo- pharynx/orbit involvement.

Nx – cannot be assessed N0 – no LN mets. N1 – single ipsi. LN < 3cm N2a – single ipsi. LN >3cm but <6cm N2b – multiple ipsi. LN <6cm. N2c – bilat., contralat. LN >6cm N3 – LN >6cm

Mx – cannot be assessed M0 – no distant mets. M1 – distant mets.

STAGE GROUPING STAGE 0 – Tis N0 M0 STAGE I – T1 N0 M0 STAGE II – T2 N0 M0 STAGE III – T3 N0 M0, T1-T2-T3 N1 M0 STAGEIV – T4 N0-N1 M0, any T N2-N3 M0, any T any N M1

5 yr. survival WHO type 1 – 10%. 5 yr. survival WHO type II-III – 50%. Poorer survival with higher stages.

CANCER OF THE SALIVARY GLANDS Rare and accounts for 6% of all head and neck malignancies.

RISK FACTORS FOR MALIGNANCY Increased risk Radiation exposure Full mouth dental x rays Skin cancer Rubber industry Nickel exposure Hair dye Silica dust Kerosene cooking fuels Vegetables preserved in salt

Decreased risk High intake of liver High intake of dark yellow vegetables note: high in vit A and C.

DIAGNOSIS OF SALIVARY GLAND CANCER Clinical presentation is indistinguishable bet. benign and malignant dis. Mobile, painless non rapid growing mass is common for both benign and malignant dis. Malignant salivary neoplasms is painless mass in 75% of patients. 6%-29% patients initially have pain. 6%-13% patients with facial palsy. Pain, nerve palsy, trismus, LN pos., fixation, numbness, loose dention and bleeding suggest CA.

IMAGING Well defined mobile tumors may be approached with out imaging. Radiologic evaluation is helpful to det. extent of disease. SIALOGRAPHY-not useful in diagnosis of malignancy of salivary glands. ULTRASOUND-limited for tissue biopsy guidance in FNAB.

CT SCAN- with contrast provides excellent detail of tumor volume, vascularity, bony structures and deep tissue involvement as well as survey of LN. MRI- excellent soft tissue detail, vascular anatomy. PET SCAN- seems to have a role in staging and to rule out distant and regional spread

FNAB For histologic confirmation and counseling. Over all accuracy of FNAB is bet. 54%98% False negative of 4% False positive of 16% Relies on ability and experience of cytopathologist

FROZEN SECTION Distinguishes benign from malignant with 94.7% accuracy, sensitivity of 100% specificity of 87.5%. Other studies show false positive bet. 3%12%. Analysis of salivary gland CA with FS is risky. It is helpful in determining LN pathology/involvement.

STAGING

HISTOLOGIC TYPES

MUCOEPIDERMOID CA most common salivary gland malignancy. Most common salivary malignancy in children. classified into low (G-I), intermediate (G-II) and high grade (G-III) malignancy. 5 year survival for G-I, G-II, G-III is 95%, 72%, 0% respectively.

ADENOID CYSTIC CA Most common malignancy of minor salivary glands and submandibular glands. 71% arising from the minor salivary glands. Hard palate most commonly involved in the oral cavity. 10%-15% malignancy of the parotid. Tenacious tumor. Tendency towards local and distant recurrences. Prediliction for neurotropic/nerve spread. LN involvement infrequent. High degree of distant spread.

ACINIC CELL CA Rare and composes 6%-8% of salivary malignancies. Low grade behavior and assoc with best survival rate of any salivary malignancy. Second most common salivary malignancy in children.

SQUAMOUS CELL CA Rare and most are a result of lymphatic or direct spread from skin and aerodigestive tract SCCA. Over all 5 year survival 24%-50%. Mucoepidermoid of high grade may be mistaken for SCCA.

MALIGNANT MIXED TUMORS Generic category encompassing carcinoma expleomorphic adenoma, carsinosarcoma and metastasizing mixed tumor. Account for 5%-12% of salivary malignancies. Malignant degeneration of 3%-7% is seen in pleomorphic adenomas (carcinoma expleomorphic adenoma) True malignant mixed tumors are composed o simultaneous elements of sarcoma and carcinoma. Assoc with 50% mortality in 5 years.

ADENOCARCINOMA Comprise 16%-20% of salivary malignancies. Low and high grade forms. Palate is most commonly affected in the oral cavity. Minor salivary glands-68%, Parotid-28%, submandibular – 4%

MANAGEMENT SURGERY Superficial parotidectomy is the minimal surgery Total parotidectomy for deep tumor extension Extended parotidectomy – involves resection of masseterand part os ascending mandible. facial nerve sacrifice is not advocated. Every attempt is made to preserve the nerve. Grafting when necessary with another sensory nerve.

NECK DISSECTION advocated for clinically positive disease’ Elective neck dissection of levels 1-3 is advocated for tumors > 4cm, SCCA, adeno. CA, Undiff. CA and high grade mucoepidermoid CA.

RADIATION Indications of post op radiation: high grade tumors SCCA malignant mixed CA adeno CA high grade mucoepidermoid CA close of positive margins CN VII involvement perineural spread bone/connective tissue involvement LN mets. extranodal extension recurrent dis.

CHEMOTHERAPY Primarily for patients with recurrent, metastatic or unresectable disease.

CANCER OF THE LARYNX

Risk factors: Laryngeal Ca - cigarette smoking thirteenfold increase among smokers - thirty-four fold increased risk if also a drinker of 1.5 li/day of wine - chemical carcinogens in workplace (asbestos, nickel, mineral oils) -genetics and susceptibility to cancer are hard to separate from lifestyle and environment - gastroesophageal reflux noted in 84% of cases

Diagnosis evaluation of hoarseness of more than 4 weeks dysphagia usually due to supraglottic or hypopharyngeal lesions airway obstruction with no apparent voice changes may represent large supraglottic or subglottic lesions endoscopy with biopsy imaging studies

MANAGEMENT Usually SCCa hyperkeratosis, hyperkeratosis with atypia, carcinoma in situ, superficially invasive carcinoma (invasion deep to the basement membrane), invasive carcinoma

Glottic Ca less biologically aggressive than supraglottic and hypopharyngeal Ca due to sparse submucosal lymphatics radiotherapy or consaervative management for early stage partial laryngectomy salvage surgery with total laryngectomy/ postop radiotx

Sub glottic Ca unusual clinically present with airway obstruction usually require total laryngectomy because involvement of laryngeal framework is frequent ipsilateral thyroidectomy with paratracheal node dissection is necessary

Supraglottic Ca early (epiglottic) tumor may be excised endoscopically or with carbon dioxide laser preepiglottic space invasion worsens the prognosis (due to lymphatic spread to both sides of the neck) partial (supraglottic) laryngectomy transglottic involvement with cord fixation warrants total laryngectomy

NECK DISSECTION Neck dissection or cervical lymphadenectomy refers to the systematic removal of lymph nodes with their surrounding fibrofatty tissue from the various compartments of the neck Eradicates cancer metastases to the regional lymph nodes of the neck Indications for neck dissection depend not only on the presence of palpable disease (therapeutic neck dissection) but on factors that increase the risk of occult disease, such as size and characteristics of the primary tumor (elective neck dissection)

CERVICAL LYMPH NODE GROUPS Level I – submental and submandibular (lip, buccal mucosa, anterior nasal cavity, soft tissues of the cheek)

Level II – upper jugular lymph nodes - upper third of IJV adjacent to spinal accessory, extending from level of carotid bifurcation (surgical landmark) or hyoid bone (clinical landmark) to skull base Level III – mid jugular nodes - below level II to junction of omohyoid muscle with internal jugular (surgical landmark) or cricothyroid memberane (clinical landmark)

Level IV – lower jugular chain - from level III to clavicle Level V – posterior triangle group - nodes located along the spinal accessory, along cervical transverse artery and along supraclavicular area Level VI – anterior neck compartment nodes - from hyoid bone to suprasternal notch - perithyroid, paratracheal, precricoid (Delphian) nodes - thyroid gland, apex of piriform sinus, subglottis, cervical esophagus, trachea

CLASSIFICATION OF NECK DISSECTION Radical Neck Dissection – standard cervical lymphadenectomy including nonlymphatic structures (SCM, IJV, SA Modified Radical – preservation of one or more nonlymphatic tissues (SCM, IJV, SA) Selective – preservation of one or more nodal groups Extended - removal of additional lymphatic and/or nonlymphatic tissues

RADICAL NECK DISSECTION Definition - removes all ipsilateral cervical node groups extending from body of mandible to clavicle, lateral border of sternohyoid, hyoid and contralateral anterior belly of digastric, to anterior border of trapezius - levels I-V, SA, IJV, SCM, few nodes at tail of parotid Indication - extensive lymph node metastasis or extension beyond capsule of the node to involve the spinal accessory and internal jugular - node disease surrounding spinal accessory even without gross SA or IJV involvement

MODIFIED RADICAL NECK DISSECTION Definition - en bloc removal of lymph node bearing tissues from one side of the neck (levels I-V) with preservation of one or more nonlymphatic tissues (SCM, SA, IJV) Indication - remove probable or grossly pathologic visible lymph node disease that is not directly infiltrating or fixed to the nonlymphatic tissue; - because SA is rarely directly invaded by metastatic disease like the hypoglossal and vagus nerves which also lie in the same proximity to the nodal disease

SELECTIVE NECK DISSECTION Definition - en bloc removal of one or more nodal group at risk for harboring metastatic cancer, an assessment of which is based on the location of the tumor Rationale - lymphatic drainage of mucosal surfaces follow relatively constant and predictable routes - in the absence of metastasis to the first echelon nodes, lower nodes are most likely uninvolved

Supraomohyoid (Levels I-III) - oral cavity cancer who are at risk for harboring occult nodal disease - 20% risk for occult disease even if no clinical evidence of nodal disease - done as elective neck dissection on contralateral side for primary lesions involving floor of mouth, ventral or midline tongue in whom ipsilateral neck dissection is planned and no definite postop irradiation is indicated

Lateral (Levels II-IV) - removing nodal diseases associated with carcinomas originating in the pharynx, larynx, and hypopharynx - because the primary site is at midline with bilateral lymphatic drainage, neck dissection is usually done on both sides.

Posterolateral (Levels II-V) - removing nodal diseases associated with cutaneous malignancies and soft tissue sarcomas located in the posterior scalp, nuchal ridge, occiput or posterior upper neck - encompass the lympn node-bearing areas of posterior and lateral compartments of the neck

Anterior Compartment (Level VI) - eradicate nodal metastasis from the anterior compartment of the neck, with cancers originating in the thyroid gland, hypopharynx, cervical trachea, cervical esophagus, and laryngeal tumors below the glottis - removal of perithyroidal, paratracheal, pretracheal, precricoid (Delphian) nodes and those along the recurrent nerve - may be done on one side only for unilateral laryngeal and hypopharyngeal lesions

EXTENDED NECK DISSECTION - neck dissection extended to remove the retropharyngeal nodes (primary sites from pharyngeal wall or oral cavity ), hypoglossal nerve, levator scapulae muscle or the carotid artery

COMPLICATIONS

Loss of trapezius function due to removal of spinal accessory nerve decreased ability to abduct shoulder above

90degrees at the shoulder with pain, weakness and

deformity of

shoulder girdle Air leaks - circulation of air thru a wound drain - communication of wound with tracheostomy Facial/cerebral edema - due to mechanical problems with venous drainage - resolves in time after collateral circulation is established Blindness - 5 cases reported in literature - intraorbital optic nerve infarction due to intraop hypotension and severe venous distention

Chylous fistula - occurs in 1-2% of neck dissection - when apparent immediately after surgery and chylous leak exceeds 600 ml/day, early exploration is preferred before the tissues become markedly inflamed and fibrinous materials coats the tissues which may obscure important structures (e.g. vagus, phrenic n.) - if less than 600 ml/D and becomes apparent only after enteral feeding, conservative management with closed wound drainage, pressure dressing and low fat nutritional support

Bleeding Carotid artery rupture - most feared and most commonly lethal complication - exposure of carotid from flap breakdown or fistula formation (malnutrition, DM, infection, radiotherapy) - use flawless surgical techniques in closure of oral and pharyngeal defects, use of dermal grafts, levator scapulae muscle flaps and controlled pharyngostomes

LYMPHOMA OF THE HEAD AND NECK Usually present as cervical lymphadenopathy Approximately 10% of lymphomas occur in head and neck extranodal sites including Waldeyer’s ring paranasal sinuses, nasal cavity, larynx, oral cavity, salivary glands, thyroid, and orbit In the US, it is the second most common tumors in the head and neck region In children, presents as the most common head and neck malignancy

Hodgkin’s Disease usually present as cervical lymphadenopathy unusual to present at an extranodal site more common in male patients with a major peak in the 3rd decade of life Most important predictor of outcome is the stage of the disease increased risk for family members of patients with the disease, 10X grater incidence for same-sex siblings may have a relationship with EBV Reed-Sternberg cells pathognomonic spread from the neck to the mediastinum, spleen and liver (staging laparotomy) bone marrow

Non-Hodgkin’s Disease 5X more frequent than Hodgkin’s disease in the head and neck region extranodal presentation is twice as frequent as nodal presentation predominantly disease of elderly, peak at 5th and 6th decade of life but is now changing due to association with HIV most important predictor of outcome is histologic appearance of the node classified according to morphologic appearance with usual clinical behavior (low, intermediate, high grade)

Ann Arbor Staging I A single lymph node or extralymphatic site II Two or more lymph node regions on the same side of the diaphragm or localized extralymphatic site with one or more lymph node regions on the same side of the diaphragm III Lymph ode regions on both sides of the diaphragm and possible localized involvement of an extralymphatic site or the spleen IV Disseminated involvement of one or more extralymphatic organs or tissues

Management Hodgkin’s Radiotherapy for early stage (Stage I, II) Radiotherapy with chemotherapy for late stages Non-Hodgkin’s Low grade lymphomas are treated palliatively because they are usually not curable Truly localized diseases are treated with radiation Advanced diseases in patients below 55 y/o may evaluated for experimental chemotherapy and bone marrow transplantation Asymptomatic elderlies may be observed

Non-Hodgkin’s Low grade lymphomas are treated palliatively because they are usually not curable Truly localized diseases are treated with radiation Advanced diseases in patients below 55 y/o may evaluated for experimental chemotherapy and bone marrow transplantation Asymptomatic elderlies may be observed Intermediate or high grade types are approached with curative intent with combined chemo- and radiotherapies

EVALUATION OF UNKNOWN PRIMARY NECK MASS If history, PE and routine tests do not lead to a definite diagnosis, any unknown neck mass, particularly a unilateral, asymptomatic mass corresponding to the location of known lymph node groups must be considered a metastasic neoplastic lesion unless proven otherwise Endoscopy with guided biopsy Fine needle aspiration and open biopsy Open excisional biopsy

MANAGEMENT OF UNKNOWN PRIMARY Assymmetric enlargement of one or more cervical lymph node in an adult is almost always cancerous Primary cervical malignancy is rare Almost all malignant cervical tumors are metastatic except for lymphomas Immediate removal of an enlarged lymph node for diagnostic purposes is a disservice to the patient with metastatic cervical carcinoma (increased incidence of distant mets, late regional recurrences and wound complications due to disruption of lymphatic drainage and manipulation of a metastasis decrease the chance for clean surgical excision and cure)

50-67% of cases, primary sites identified by careful routine PE Independent second survey of less visible areas of the upper digestive and respiratory tract Needle biopsy of neck mass Endoscopy is negative, sites most likely to contain an occult tumor should be biopsied Location of the node is a guide to sites for biopsy posterior triangle – nasopharynx jugulodigastric – tonsils, tongue base, supraglottic larynx supraclavicular – digestive tract, breast, tracheobronchial tree, thyroid, genitourinary If still negative, open excision with planned surgery and neck dissection

Postop irradiation is sometimes advocated but still controversial - may compromise management of mucosal carcinoma appearing later - may induce later mucosal carcinoma - cause prolonged morbidity in the form of xerostomia, dysphagia, dental caries - cure rates higher with surgery alone - best candidates are those with N2, N3 (N1 with nodal capsular penetration)