Tumours of the head and neck

August 10, 2011 | By | Reply More

Tumours of the head and neck

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Tumours of the head and neck

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


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
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
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
The  spectrum of malignant  tumours to affect the  oral cavity vary widely  and includes:
Surface epithelium
Squamous cell carcinoma over 90%
Glandular epithelium
Adenocarcinomas in females
Mucoepidermoid carcinomas in males
Mesenchymal tissues
Lymphomas, Sarcomas are very rare

Surface  Epithelium

1-  Squamous cell Carcinoma

Undifferentiated carcinoma
Differentiated carcinoma
Adenoid squamous carcinoma
Verrucous carcinoma

2-  Basal cell carcinoma

3-  Malignant Melanoma

Glandular  epithelium

1-  Adenocarcinoma

2-  Mucoepidermoid carcinoma

3-  Adenoid cystic carcinoma

4-  Acinic cell carcinoma

5-  Undifferentiated carcinoma

Mesenchymal  tissues

Osteogenic sarcoma
Neurogenic sarcoma
Synovial cell sarcoma
Hodgkin’s & non-Hodgkin’s lymphomas
Plasmacytoma & multiple myeloma

Metastatic  carcinoma, sarcoma

Prognostic  Indicators:
Sex: Poor prognosis in females
General condition & health status of patient
T stage
Number of histologically positive nodes
Surgical margin status
Type of therapy and blood transfusion

Alcohol consumption
They have synergistic role
Burning tar gives off a variety of active substances e.g. benzopyrene, methyl cholanthrine, which will be broken by arylhydrocarbon hydroxylase into epoxide, carcinogen, that bind to the DNA
Snuff dipping and Shama user

Chronic  irritation from sharp jagged teeth
Asbestos, Nickel-Chromate, in nasal and paranasal sinuses tumours
Wood dust in Adenocarcinoma of the nose
Dietary factors:
Vitamin A deficiency
Vitamin B deficiency, Patereson-Kelly syndrome
Radiation exposure
Human Papilloma Virus HPV
Epstein-Barr Virus EBV
Human Immunodeficiency Virus HIV
Hepatitis virus
Acquired  capability of cancer  cell:
Limitless replicative potential
Evading apoptosis
Self-sufficiency in growth signal
Insensitive to antigrowth signals
Sustained angiogenesis
Tissue invasion and metastasis


Clinical  Examination:
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
The majority of cases are potentially treatable

Whether  to treat or not  depend on:
the age
the health status of the patient
advance stage
local disease

Full  assessment will lead  to one of the following  conclusions:
Patient is potentially curable
Primary tumour is curable but patient develop another illness
Patient is incurable but should be treated
Patient is incurable and should not be treated

Patient are generally over 45 years.
Tumours affecting younger age group are usually sinister, defective immunological make-up
Most tumours are of epithelial origin and they require years of abuse by smoking and tobacco
Tumours in younger patients, who do not smoke, is usually very sinister
Tumours developing in an immuno-compromised patients do not respond to any treatment modality

Vary widely and is often unreliable
Painless lump which persisted for a varying period of time
Persistent ulceration
Difficulty of wearing denture
Later Symptoms:
Pain locally or referred to the jaw or ear
Difficulty with chewing food and swallowing
Altered speech and respiratory difficulty
Asymptomatic and noticed during routine dental examination

The  patient general condition:
Assessed with full investigation and classified for performance status
Grade 0 Fully active without restriction
Grade 1 Ambulatory but restricted in physically    strenuous activity
Grade 2 Ambulatory but unable to carry out any    work activity
Grade 3 Confined to bed but capable of limited    self care
Grade 4 Confined to bed and unable to carry out any   self care

Karnofsky  Status

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

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
Primary site:
Histological type, size and extend of the primary
Node metastasis
Haematogenous metastasis

Primary  Tumour:
Indicated by the letter T and the suffix 1,2, 3 or 4 represent more advancing disease
T1 – tumour 2 cm or less
T2 – tumour more than 2 but less than 4 cm
T3 – tumour more than 4 cm
T4 – Tumour more than 4 cm with deep invasion of underlying tissues
T0 – No evidence of primary tumour
Tis – Carcinoma in Situ
TX – Extend of primary tumour cannot be assessed

Lymph  node:
Is used to describe progressive lymph node involvement
N1 – Single epsilateral nodes 3 cm or less in diameter
N2 – Single epsilateral nodes more than 3 cm but less than 6 cm, or multiple clinically positive epsilateral less than 6 cm
N2a – Single
N2b – Multiple
N3 – Clinically positive epsilateral more than 6 cm, Bilateral or contralateral
N3a – Epsilateral more than 6 cm
N3b – Bilateral, each side staged separately
N3c – Contralateral only

Distant  metastasis:

M0 – No metastases present

M1 – Metastases clinically demonstrable

MX – Metastases cannot be assessed

TNM  Staging:
Stage I: T1, N0, M0
Stage II: T2, N0, M0
Stage III: T3, N0, M0

T1, 2 or 3, N1, M0

Stage IV: T4, N0 or 1, M0

T1 – 4, N2 or 3, M0

T1 – 4, N1 – 3, M1

AJCC  1983

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

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