Anda di halaman 1dari 54

Y  




 
Introduction

‡ Head and neck cancer


is remarkable for its
ability to cause
extensive local tissue
destruction and regional
node involvement in
the absence of distant
metastasis
Introduction
‡ Tumours are usually confined to
the primary sites

‡ Regional nodes & haematogenous


metastasis are very rare and late in
the disease process

‡ Loco-regional treatment by either


surgery, radiotherapy or
combination of the two is
frequently curative
Introduction
‡ Many of the oral lesions may
have had an initial lesion that
were potentially curable.

‡ The cure could be predicted if


the lesion is diagnosed early
and the appropriate therapy is
given before the disease
reaches advance stages to
become incurable
Introduction
‡ Cancer of the oral cavity in Saudi
Arabia is not an uncommon
disease
‡ It account for more than 25% of
all malignancies, in the Southern
region, it might reach up to 35%
‡ In males, it is third in frequency
following lung and prostate
cancer
‡ In females, it is second following
breast cancer
Introduction
‡ Y  
  

 
 
      
‡ V 
   
‡ V 
  


‡ ½

   
‡ m
 
  
‡ 

 
 
‡ ð  
 
‡  
V 
  
Introduction
V 
  
ë V 
  

‡    

‡    

‡ m
 

 

‡ 
 

     

   

Introduction
½

   
ë m
 

 


 

m

 

! m  

"   
 

Introduction
ð  
 
ë V 

‡ #$
 

‡ % 

 

‡ &
 

‡ 

 

‡ '
 

‡ m
 

‡ V
   

 
()*
 
()
 

   
*   


! (  
   
 

Introduction
‡ Ñ   
:
‡ V+



  
‡ , 

*    
 
‡ Y 
‡ ' $
 

 


‡ V   
‡ Y
   $

  

Introduction
‡ m 
‡ V
(
‡ m 


 

‡ Y  

‡  
  
 $ 
$-
   
    
$$
($  
 $
 
+ 

  
 $
 'm
‡ V  V 
Introduction m 
‡ Chronic irritation from sharp jagged teeth
‡ Chemicals:
‡ m$
'(  
       


‡ .

m
 

 

‡ Dietary factors:
‡  m 
‡    
  

‡ Radiation exposure
‡ Viruses
‡   

‡ /  /
‡  0 
 0
‡  
Introduction
‡ m   
      
‡ Limitless replicative potential
‡ Evading apoptosis
‡ Self-sufficiency in growth signal
‡ Insensitive to antigrowth signals
‡ Sustained angiogenesis
‡ Tissue invasion and metastasis
Assessment
‡ ] 



 
‡ Tumours, when first seen,
are almost always confined
to the head and neck with
no distant metastasis
‡ Head and neck tumours are
rarely irremovable, all
structures can be removed
with the tumour in
continuity and repaired later
‡ Y  1

  

   $ 
Assessment
‡ .  
 




‡   
‡      
 
 
‡   
‡
  
Assessment
‡ #      



 



 

‡  
 
 $ 
‡  

 $ $ 

 
  
‡   $ $

 $ 
‡   $  

 
$ 
Assessment
‡ i
‡ m
‡    
!" 
‡ Y
 
 
  
  

  ( 
‡ 

 
   
  
  
 $$
( 
$ 

‡ Y

 



(
 
‡ Y

  



 



   
 
Assessment
‡ 
 
‡    

  $ 
‡       

  

 
‡   

‡   
 
‡  V 

‡  
 
 
 
1 
 
‡     

 


‡ m    

  
‡ m 
 


 
+  

Assessment
‡ The patient general condition:
‡ Assessed with full investigation and classified for
performance status
ë ½
 #  


 ½
ë m $ 
$  

 
 ½
 m $ 
$ $ 
 
 

( 
½
 
 
$$  $ 
  
  
 ½
 
 
$  $ 
 
 
  

 V
 
Assessment
‡ 

 :
‡ Think in term of T Staging, delineate its border
by inspection and palpation
‡ Record and draw the lesion from different
angles using normal anatomical landmarks
‡ The status of teeth should be assessed as
causative and if radiotherapy is to considered
Assessment
‡ Staging of cancer:
‡ Subdividing the malignant lesion into groups
with similar behaviour
‡ Act as a guide to appropriate treatment
‡ Act as a guide to prognosis
‡ Permits more reliable comparison of results
‡ Ñ
 
‡ Histological type, size and extend of the primary
‡   


‡ i

   


Staging
‡ Ñ
Y  
‡ Indicated by the letter T and the suffix 1,2, 3 or 4
represent more advancing disease
‡ Yë ± tumour 2 cm or less
‡ Y ± tumour more than 2 but less than 4 cm
‡ Y ± tumour more than 4 cm
‡ Y ± Tumour more than 4 cm with deep invasion of underlying
tissues
‡ Y ± No evidence of primary tumour
‡ Y ± Carcinoma in Situ
‡ Y2 ± Extend of primary tumour cannot be assessed
Staging
‡ Lymph node:
‡ Is used to describe progressive lymph node
involvement
‡ ë ± Single epsilateral nodes 3 cm or less in diameter
‡  ± Single epsilateral nodes more than 3 cm but less than 6
cm, or multiple clinically positive epsilateral less than 6 cm
‡ ' ± Single
‡ '$ ± Multiple
‡ ± Clinically positive epsilateral more than 6 cm, Bilateral
or contralateral
‡ ' ± Epsilateral more than 6 cm
‡ ' $ ± Bilateral, each side staged separately
‡ '  ± Contralateral only
Staging
‡ Distant metastasis:

‡  ± No metastases present

‡ ë ± Metastases clinically demonstrable

‡ MX ± Metastases cannot be assessed


Staging
‡ TNM Staging:
‡ Stage I: Të, N, M
‡ Stage II: T, N, M0
‡ Stage III: T , N, M
Të, 
 , Në, M
‡ Stage IV: T!, N
ë, M
Të  !, N
 , M
Të  !, Në , Më
m]]ë
Staging
‡ Stage I
‡ compromise negative nodes and operable primary
‡ Stage II
‡ operable primary with operable nodes
‡ Stage III
‡ inoperable due advanced primary or advanced nodal
involvement
‡ Stage IV
‡ Distant metastases preclude any surgical intervention
Surgical anatomy
‡ Y 
‡ 
 
 ( -
   
   
      

 
 $ 

 
 
‡ &   
$

 

 
$ 
  
$
    

     
 

‡ Y        

      
 
$ +    
Surgical anatomy Y 
‡ Lymphatic drainage:
‡ Mucosal and cutaneous systems.
‡ Lower lip:
‡ One medial trunk which drain the inner third of the lip into
the submental group
‡ Two lateral trunk which drain the outer two-third into the
submandibular lymph nodes
‡ Anastomosis account for bilateral metastases
‡ Upper lip:
‡ Drain into the periauricular, parotid, submandibular and
submental lymph nodes
Surgical anatomy Y 
‡ Age and sex:
‡ Y +    
  
3ë
‡ 93% affect the lower lip with
squamous cell carcinoma, exophytic
type
‡ 5% in the upper lip and commonly
basal cell carcinoma, commoner in
females
‡ V
+

  


 
 
‡ 

 
 +

‡ V
(  
‡ 0  V   -
   
 
Surgical anatomy
‡ The buccal mucosa:
‡ Covered with non-
keratinizing stratified
squamous epithelium with
multiple minor salivary
glands
‡ It is tight over the
buccinator muscle and fixed
to the upper and lower sulci
‡ Lymphatic drainage:
‡ The submandibular
lymph nodes to the
lower deep cervical
chain
Surgical anatomy
‡ Y   
‡ Specialized keratinized
epithelium with collection
of minor salivary gland and
muscle fibres
‡ The interlacing muscle
fibres form an easy pathway
for cancer spread and the
constant movement of the
tongue disseminates the
disease widely
‡ Excision should be wide
with 2 cm safe margin
Surgical anatomy Y  
‡ A disease of the middle age and
elderly with equal sex incidence
‡ 85% occurs in the lateral border
of the anterior 2/3 while tip,
dorsum and ventral surface are
rarely involved
‡ The lesion may be infiltrative
(small on the outside but
palpation shows deep invasion)
or exophytic and usually of the
well-differentiated type
Surgical anatomy Y  
‡ Lymph drainage:
‡ Y
 

‡ Y
 $     
 
 

  
‡ Y  
4 
‡  
  
1





‡ V 
      

‡ Y 

ë4 
‡  
   
‡ Y     
 

 $    
(
$     
‡ Y   


 
  

 $ $    

‡      
  

 
 
Surgical anatomy
‡ Y   :
‡ m   


‡ Commoner than the lateral part
‡ Spread medially into the ventral
surface of the tongue and
laterally
‡ Deep spread to the base of the
tongue and the hyoglossus and
genioglossus muscles
‡ Shows bilateral lymphatic spread
to the submandibular and the
submental nodes
Surgical anatomy Y   
‡ 
 


‡ Spread medially to the side of the tongue
‡ Lateral spread to the alveolar ridge where presence
or absence of the teeth govern the outcome:
‡ Teeth act as a barrier against buccal spread
‡ In edentulous patient, the alveolar process has resorbed
and cortex is incomplete, tumour reaches the cancellous
spaces and the canal and spread through the nerve.
‡ Deeper spread, mylohyoid muscle act as a barrier
anteriorly, posteriorly the floor is close to the skin,
appear as a palpable lump in the submandibular area
Surgical anatomy
‡ Y 
 
‡ Carcinoma of the lower
alveolus affects the antero-
lateral part and spread to the
floor of the mouth
‡ Tongue and floor of the mouth
tumours reach the lower
alveolus by marginal spread in
the mucosa and submucosa
overlying the sublingual,
submandibular glands and the
mylohyoid muscle.
Surgical anatomy Y 

‡ They act as barrier against deep infiltration

‡ Alveolar bone above the mylohyoid line is initially


affected

‡ Edentulous jaws, mylohyoid line is on the occlusal


ridge and the loss of the cortical bone barrier will
allow tumour to spread downward into the
medullary cavity
Surgical anatomy Y 


‡ The inferior alveolar nerve provide a pathway


for perineural spread in a predominately
proximal direction with little involvement of
the bone
‡ Nerve looks clinical normal till late
‡ Spread is not continuous, multiple pathological
samples is required
‡ Lymphatic spread to the submandibular lymph
nodes
Surgical anatomy
‡ Y 
 

 
‡ 


 

 


  
   
‡  

 

$  
‡ V 
  

   

+
  

‡ 0  $
    
 
‡ 0
      

‡   
$ $ 
  
‡  
   56 
 7
‡ 


 
Surgical anatomy
‡ Y 

 
‡ The sinus is related to the
orbit, nose, alveolar
process, infratemporal fossa
and nasopharynx.
‡ It has an outlet to the nose,
ethmoid sinuses and the
root of the teeth
‡ The posterior ethmoidal
air cell is separated from
the optic nerve by a bar of
bone but it is missing in
10% of cases and only
encased in a sheath of
dura, extension into the
brain.
Surgical anatomy Y 

 
‡ The inferior orbital fissure provide a route for entry
of tumours into the orbit, the periostium offer an
excellent resistant barrier to spread into the orbit
‡ The roots of the upper premolars and molars and the
alveolus are in intimate contact to the floor
‡ The infratemporal fossa is the space behind the
maxillary antrum and it connects to the para-
pharyngyeal space, and the sphenoid bone
superiorly with foramen spinosium and ovale with
their emerging nerves
Surgical anatomy Y 

 
‡ Lymphatic drainage:
‡ Not fully understood
‡ Drain posteriorly to the retropharyngeal nodes
‡ Directly to the jugulo-digastric nodes
‡ If it cross to the nose or the cheek it will drain to
submandibular lymph nodes
‡ Aetiology:
‡ Wood dust, nickel, shoe factory and mustard
gas
‡ Snuff is a contributing factor
Surgical anatomy Y 

 
‡ Classification
‡ Yë - confined to the mucosa of the infrastructure
‡ Y confined to the mucosa of the suprastructure
without bone destruction
- confined to infrastructure mucosa with bone
destruction of medial and inferior wall only
‡ T3 - More extensive tumour invading the cheek,
the orbit, anterior ethmoid and pterygoid
muscle
‡ T!± Invading the cribriform plate, posterior ethmoid
and sphenoid sinuses, nasopharynx, pterygoid plat and
the base of the skull
Surgical anatomy Y 

 
‡ ð

  
‡ V 
  

‡ 50% of all malignant lesions of the sinus
‡ Bone destruction and invasion of nose, ethmoid, orbit, anterior wall
and cheek, and palate or alveolar ridge and buccal sulcus
‡ m
 

‡ Uncommon, occurs in people working in wood industry
‡ Histologically two types, high or low grade
‡ Invade bone and present the same way like SCC
‡ m
 

‡ Shows as solid areas of cells instead
‡ Distant metastasis and perineural invasion, infra-orbital, maxillary,
greater palatine and olfactory nerves
Diagnostic Techniques
‡ Y 
‡ Y    


 

    




‡ #   

‡ A 22-gauge needle
attached to small volume
syringe
‡ Smear is prepared and
stained after fixation with
alcohol
‡ Minimize tumor spillage
and sample error in small
lesion
Diagnostic Techniques
‡ Y
$  
 
‡ Acidophilic metachromatic
nuclear stain that colors
sites of squamous cell
carcinoma but not adjacent
normal mucosa surfaces

‡ 1 ± 2% applied to dry
surfaces and the dye diffuse
into tissue through the large
intercellular canaliculi
Diagnostic Techniques
‡ 0
 
‡ V 


  

   1 
 

   

 

‡ Y
 - 
 
 -
$

 
 
‡ 
   
 
 
 

  
‡ /+
 
‡ %
 
  

‡ 
   
  
Surgical anatomy
‡ R


‡ %
2 % 
‡ Useful in cases of bony involvement
‡ Panoramic views shows lytic lesions
‡ Lateral soft-tissue films shows the extend into the nasopharynx
or hypopharynx
‡ m
  
‡ Define oral malignancy ± mainly avascular
‡ Shows the relation to major vessels prior to surgery
‡ Selective transcatheter embolization for bleeding control or
decreasing tumor vascularity preoperatively
Diagnostic Techniques
‡ Sialography:
‡ Cannulation of parotid and submandibular ducts and the
infusiopn of contrast material
‡ CT-Scan:
‡ Define the gross limits and determine the actual depth of tumor
‡ Evaluate adjacent bony structures and erosions involving the
paranasal sinuses, base of skull and the cervical spine
‡ Magnetic Resonance Imaging:
‡ Gives a better resolution for soft tissue tumors
Diagnostic Techniques
‡ Nuclear Scanning:
‡ The use of tumor-seeking radiopharmaceutical
material
‡ Bone scanning:
‡ Uses Technetium 99-labeled phosphate complexes
‡ Very sensitive and positive in the presence of bony lesions
before their detection by conventional radiographs
‡ Lacks specificity, infection, inflammation and even trauma
result in positive scan
Diagnostic Techniques
‡ Salivary gland scanning:
‡ I.V. Technetium shows an increased uptake in papillary
cystadenoma.
‡ Might occur with other benign or malignant tumors as a
focal areas
‡ Gallium-67 scanning:
‡ Gallium isotopes concentrate in a rapidly growing tumors
‡ Best in epidermoid carcinomas and lymphomas
‡ Used in lymphoma staging
Diagnostic Techniques
‡ Tumor markers:
‡ Tumor markers are molecules occurring in blood or
tissue that are associated with cancer and whose
measurement or identification is useful in patient
diagnosis or clinical management.
‡ Tumor markers are most useful for monitoring response
to therapy and detecting early relapse
‡ They are generally products of the cancer cell, although
none is unique to cancer cells; they represent aberrant
tumor production of a normal element
Diagnostic Techniques
‡ Tumor markers can be used for one of four
purposes:
‡ 1- screening a healthy population or a high risk
population for the presence of cancer
‡ 2- making a diagnosis of cancer or of a specific type
of cancer
‡ 3- determining the prognosis in a patient
‡ 4- monitoring the course in a patient in remission or
while receiving surgery, radiation, or chemotherapy.
Diagnostic Techniques
‡ ] 
  m ] m
‡ The CEA was one of the first oncofetal antigens to be
described and exploited clinically.
‡ It is a complex glycoprotein and is associated with the
plasma membrane of tumor cells, from which it may be
released into the blood.
‡ The primary use of CEA is in monitoring colorectal
cancer, especially when the disease has spread and to
check recurrence
‡ Other cancers produce elevated levels of this tumor
marker, including lymphoma, head and neck cancer and
cancers of the breast, lung, pancreas