6. Head & Neck Malignancy Flashcards
Describe the step wise progression of squamous cell carcinoma?
Dysplasia to carcinoma in situ to invasive cancer
What are the risk factors for cancer of the head and neck?
Smoking Alcohol Betel Nut Genetic not proven Poor dentition HPV
Why is the rate of ENT cancers thought to be higher is Asia?
Betel Nut/Paste Chewing
In whom does HPV tend to cause cancer? On what is this dependent? How do these patients fair?
HPV harbours in the oral cavity, significant association with development of Cancer – young non-smokers.
Frequency of sexual activity, number of partners
Response to HPV cancer much better than smoking type,
List imaging modalities used in ENT cancers in order of prof currens preference?
PET Scan
CT
MRI (more detail, more expensive)
Describe the work up for a ENT cancer?
H+N exam with FE
Biopsy / pan endoscopy
Staging
Imaging CT, Head and Neck / Chest
Pet Scan (screens the whole body, ideally for everyone for ENT cancer, to check for MET, use fluouodioxyglucose which is uptaken by tumours)
What are the early warning signs of ENT cancer?
Hoarse Neck Lump Ulcer Bloody Discharge Dysphagia Persistent Sore Throat
Anatomical classification of ENT tumours?
Oral Cavity Pharynx Larynx Skin Thyroid Salivary Gland Neck Sinuses / Nose
What is unusual about melanoma in the ENT area?
Seems to be more aggressive the ENT area for some reason.
What are the warning signs of melanoma?
Asymmetry Borders (irregular) Color (variegated) Diameter (greater than 6 mm (0.24 in), about the size of a pencil eraser) Evolving over time
At later stages, the mole may itch, ulcerate or bleed.
What is the biggest cause of melanoma?
UV Exposure.
In Melanoma what can be a therapeutic target?
BRAF gene (only 30% in Irish) can be a therapeutic target Immunotherapies.
Outline the various roles of surgical intervention in ENT cancers
Primary treatment modality
Combined modality setting
Palliative (laser and airway stenting)
Salvage surgery (following failed radiation therapy)
How might surgical interventions for ENT cancers be improved pre, intra and postoperatively?
PRE-OPERATIVE CARE Counselling Nutritional status Dental assessment Clinical Nurse Specialist Speech Therapy
INTRA-OPERATIVE
Nerve Monitoring
Technique
State of the art equipment
POST-OPERATIVE HDU/ICU Tracheostomy care Flap monitoring Rehabilitation
How long do you leave a drain in for a deep lobe tumour?
Until it draining less than 25mls/day
Where do they vast majority of laryngeal cancers occur and why?
90%+ in the glottis since that’s where the carcinogeness hit
Supraglotic region next
On what is the Tx for laryngeal cancer based?
Tx based on stage
T1 A = one cord T1 B =On what two cords. (N0M0)
Considered to be early
80% caught at these stages cured
What are possible treatments for laryngeal cancer (non-superficial, recurring)? Which is the most commonly used?
Radiation (most common in recurrent)
Partial laryngectomy
Laser (Endoscopy/Microsurgery)
(Possibly also robotic but I think this was an aside)
Chemotherapy Total Laryngectomy (May be the only option depending on the anatomy)
Why is radiotherapy the 1st line treatment for most laryngeal cancers?
Non-surgical
Daily for six weeks
Cures 80%
Preserves larynx
Laser is challanging the primacy of radiotherapy in term of cost and s/e’s
What are the disadvantages of radiotherapy as a treatment modality for laryngeal scc?
radionecrosis oedema laryngeal stenosis. Acute mucositis Pharyngitis Treatment/Recovery Time
If radiotherapy fails what is the 2nd line intervention?
Usually conservation laryngectomy
What are the advantages of external conservation laryngectomy?
Precise tumour margin control by histology,
An ability to assess nodal metastasis
Earlier return to work
Improved chances of salvage without total laryngectomy.
What are the disadvantages of external conservation laryngectomy?
haemorrhage
fistula formation
tracheostomy problems
web formation and mortality - < 1%.
What intervention can enhance cure rates for laryngeal carcinoma?
Salvage surgery
For what type of laryngeal cancers is laser surgery used?
Transoral Laser Microsurgery
Very superficial lesions
Deeper lesions possible, but require experitise and experience.
What are the advantages of Laser Endoscopic Resection?
Single Session therapy
Diagnosis, staging and therapy provided simultaneously
Low Morbidity
Minimal side-effects
Cost effective
Preservation of laryngeal function
Option of radiotherapy or surgery is retained
What are goals of contemporary laryngeal conservation surgery?
Local control of disease equal to that of a total laryngectomy.
Speak and swallow without permanent tracheostomy
What are the two standard types of conservative laryngeal conservation surgery? For which type of laryngeal cancers is each used?
Vertical partial laryngectomy (glottic cancer)
Horizontal partial laryngectomy (supraglottic)
What staging is considered to be advanced laryngeal cancer?
T3 = Fixed Cord (variable sometimes radiotherapy+surgery, sometimes total laryngectomy, sometimes conservative laryngectomy.)
T4 = Spread outside of larynx (usually total laryngectomy w/ipsilateral selective neck dissection, or conservative laryngectomy sometimes compromise survival slightly for Quality of life)
(Once N2/3 = Radical/Modified Radical Neck Dissection can be performed)
What is the treatment for advanced laryngeal cancer?
Chemoradiotherapy + Radiation (Combined Modality Treatment)
Usually try to keep the larynx
(Combination of radiotherapy and conservative surgery or radical surgery preceded or followed by radiotherapy. Selected patients may be managed with radiotherapy initially, with surgery reserved for salvage)
Contrast chemotherpay with laryngectomy?
No massive difference in survival
Fistula formation common complication of laryngectomy (up to 30%)
S/E’s
Chemotherapy - dry mouth
Surgery - loss of smell/taste, coughing, painkillers
Following trials and reviews what has been found to be the best medical Tx for laryngeal presevation in advanced laryngeal cancer?
Radiotherapy with concurrent (simultanious) cisplatin (chemo). Significantly improved vs chem then radiotherpay and vs radiotherapy alone.
What the potential complications of total laryngectomy?
About 40% experience a complications. Hematoma/Seroma Wound Dehiscence Wound Infection Fistula formation Stomal Stenosis
Name the two types of reconstructive techniques for ENT cancers studied?
Pectoralis Major Myocutaneous Flap (pharynx and cervical esophagus)
Radial Forearm Flap (skin cancer)
What are the advantages of pec major myocutaneous flap reconstruction?
Large skin territory Rich vascular supply Immediate transfer Supine position Muscle only/skin and muscle
What are the 3 broad types of neck dissection?
Radical Neck Dissection:
Modified Radical Neck Dissection
Selective Neck Dissection
What is meant by a radical neck dissection?
en-bloc resection of lymph-bearing tissue in levels I-V, SCM, IJV and Ixn
What is meant by a modified radical neck dissection?
Resection of lymph bearing tissues from levels I-V sparing one or more non-lymphatic structures.
Types 1-III, working up from 1 to 3 structures spared.
Type I : Preservation of IXn
Type II: Preservation of IXn and IJV
Type III: Preservation of IXn, IJV AND SCM.
What are main types of selective neck dissections?
Supraomohyoid: Levels I,II,III
Lateral : Levels II,III,IV
Posterolateral : Levels II,III,IV,V, suboccipital and retroauricular nodes
Anterior : Level VI, pretracheal, paratracheal and prelaryngeal nodes
What is the single most important tumor-related prognostic factor?
Status of the Cevical Lymph Nodes.
CT, MRI, Ultrasound-guided FNABx may miss small tumour deposits
In what anatomical areas is nerve monitoring important?
Parotid (Facial Nerve)
Thyroid (Recurrent laryngeal nerve)
What percentage of cancers are thyroid cancers?
1.00%
What are the surgical options for Thyroid Cancers?
Total Thyroidectomy
Partial Thyroidectomy
What are the advantages/disadvantages of total thyroidectomy?
Multicentricity Local recurrence less Decreases risk of distant recurrence Anaplastic transformation reduced RAI diagnosis / therapeutic Thyroglobulin supplementation
What are the advantage/disadvantages
Complications less likely
Mortality no different
What is a common early symptom of a glottic carcinoma? Why?
Frequently associated with an alteration in voice quality (hoarseness) in the early stages of disease.
Due to an alteration in the mass, shape and mobility of the involved cord.
Which presents earlier a glottic or supraglottic carcinoma?
Glottic
What are common late symptoms of a glottic carcinoma?
Airway obstruction and dyspnea represent late features of glottic carcinoma
Describe the predilection of SCC in the larynx
SS HA predilection for the anterior half of the true vocal corD
Can spread to Reinke’s space where it extends anteriorly and posteriorly along the vocal fold.
Deep invasion results in involvement of the vocalis muscle and the paraglottic space, lateral to the laryngeal inlet, resulting in decreased glottic mobility.
Posterior extension to the arytenoids and cricarytenoid joint will further limit cord mobility.
Why are 2/3’s of supraglottic carcinomas not diagnosed until an advanced stage?
Since non-specific symptoms are associated with supraglottic carcinoma in the early stages of the disease
What are the late stage signs of supraglottic carcinoma?
Later bulky, exophytic tumour growth or transglottic spread may cause hoarseness, dyspnoea and/or stridor.
Odynophagia and unilateral otalgia
Aspiration is not uncommon at this stage due to an incompetent supraglottic valve mechanism.
What possibility is important not to discount in any ENT cancer?
A neck mass may be the presenting complaint due to metastasis or direct tumour extension.
What is the 1st line Tx for lesions diagnosed as carcinoma in situ, within the glottis?
Managed by microscopic suspension laryngoscopy with vocal cord stripping of the involved epithelium.
Laser microscopy also accepted method for easily accessible T1 cancers.
Close follow up w/repeat laryngoscopy to exclude invasive disease, a must!
How is T1N0/T2N0 supraglottic carcinoma managed?
Same as glottic, single modality radiotherapy or partial laryngectomy. (Usually radiotherapy).
What is the recommended treatment for supraglottic carcinoma following failure of radiation therapy? Why is this?
Failed radiation cases are usually best managed by laryngectomy or near total laryngectomy rather than partial laryngectomy. Generally T1N0 and T2N0 supraglottic cancers have cure rates of approximately 75% with either surgery or radiation alone.
(SAYS THAT BUT THEN SAYS “Combined as opposed to single modality treatment shows better survival rates in patients with advanced neck disease and advanced primary cancers.” FFS!) Too much burden, S/E’s???
What is the oncologic principle behind supragottic laryngectomy?
The fact that the supraglottis is derived from a distinct region (buccopharyngeal) to that of the glottis/subglottis (tracheopulmonary) embryologically.
What is the recommended treatment for advanced (T4) supraglottic carcinomas? Why is this?
Laryngectomy is generally recommended for all T4 supraglottic cancers.
Due to the tendency of supraglottic cancers to present late, the cervical nodes must be considered in the initial treatment plan.
What is an important consideration regarding eh Patient that should be taken into account when considering a supraglottic laryngectomy?
the patient must have good pulmonary and cardiac status since aspiration is inevitable in the post-operative period.
What role do biomarkers play in therapy decisions in laryngeal carcinoma?
None there are no reliable tumour markers in LSCC
What are the well differentiated thyroid cancers?
Papillary (70-80%)
Follicular (10%)
(Hurthle Cell = Rare)
What are the four main types of thyroid cancers?
Papillary (70-80%)
Follicular (10%)
Medullary (5-7%)
Anaplastic (<4%)
What is the first step to be taken AFTER a thyroid cancer Diagnosed? Why is this?
Surgical Resection
To ensure recurrence does not occur.
What therapy’s are started in addition to surgical resection?
Radioactive iodine ablation
Thyroid suppression therapy
(Occasionally) External beam therapy.
In whom is thyroid cancer more common M/F?
Female x2 > Men
Which of the sexes has a better prognosis following development of thyroid cancer? What other factor determines prognosis?
Females usually have a better prognosis in all types of thyroid cancers when compared to males.
Over the age of 40 tend to have a more aggressive and potentially a more lethal course of behaviour.
In whom is Papillary Carcinoma common?
Young Femaless, 20-40yo
What is the pattern of papillary carcinoma spread
Tends to metastasis to regional lymph nodes
How do most papillary carcinomas present?
Single or multifocal tumours
Most asymptomatic nodules.
Advanced Stage =
Hoarseness
Dysphagia
Neck lumps
What is the prognosis for papillary carcinoma?
Excellent with current surgical and medical management
90% survival rate at 20years
In whom is follicular thyroid cancer more common?
Females 40-60yo (Older)
Often living in areas of iodine deficiency
What is the pattern of spread of follicular cancer? What are the implications of this for prognostication?
Spreads by the haematogenous route
Therefore prognosis is influenced by the extent of capsular and vascular invasion.
What kind of tumour is formed in medullary thyroid cancer?
Neuroendocrine tumour is formed
Where do tumours originate from in medullary thyroid cancer?
Tumours originate from the parafollicular C-cells and secrete calcitonin.
Describe the aetiologies of medullary thyroid cancer?
60-80% occur as sporadic thyroid nodules
20-40% are familial and associated with multiple endocrine syndrome (MEN) IIa or IIb.
In whom is medullary thyroid cancer more common? What is the 5yr survival?
Patients are older (40 to 50 years of age) and the 5 year survival rate is 60%.
In whom is anaplastic thyroid cancer more common?
Elderly ladies ≥65yo
What are the characteristic features of an anaplastic thyroid cancer?
Patients present with a rapidly enlarging thyroid mass and are symptomatic (stridor, dysphagia).
Many usually have distant metastases on presentation.
What is the prognosis usually in anaplastic thyroid cancer?
Usually dead ≤1yr
What are the investigations used on discovery of a thyroid mass?
History Physical examination Blood tests (inc Thyroid Function Tests) Fine needle aspiration biopsy (FNA) Imaging studies
What are the four different types of results which might be obtained from FNAC?
Benign
Malignant
Indeterminant for Dx (repeat)
Non-Diagnostic (repeat)
How do you improve the accuracy of FNAC results?
Do multiple FNA’s!
What are the limitations of FNAc?
A diagnosis of malignancy requires surgical intervention. (Thyroidectomy)
Whilst it is possible to diagnose papillary and medullary cancers by FNA, it is not possible to distinguish follicular adenoma from carcinoma. Thyroidectomy is required in such instances.
What is the sensitive measure of both hypo and hyperthyroidism?
Serum thyroid- stimulating hormone (TSH)
What does a low Serum thyroid- stimulating hormone (TSH) suggest?
Low serum TSH suggests a functioning nodule, which is typically benign. (High/Low TSH can never rule out malignancy)
What is the usefulness of baseline thyroglobulin?
A baseline thyroglobulin level can be useful as a tumour marker in patients with well-differentiated thyroid cancer.
What does an elevated serum calcitonin suggest?
Highly suggestive of medullary thyroid carcinoma.
(However with the low incidence of medullary thyroid carcinoma, serum calcitonin is not a cost-effective screening tool in the primary workup of thyroid nodules.)
What is the most effective imaging study for defining thyroid lesions?
Ultrasound is the most sensitive imaging tool for defining thyroid lesions.
It can detect nodules in 25% of asymptomatic patients
It can identify thyroid masses that are not palpable.
Ultrasound cannot distinguish benign from malignant nodules.
What imaging study is used to determine the functional status (ergo, the probability of malignancy) of a nodule? What is suggestive of malignancy in this imaging study? Why is it not diagnostic of malignancy?
Radioisotope scanning
Malignant nodules are typically non-functional and do not take up radiolabelled iodine and appear as cold nodules.
Benign nodules tend to be hyperfunctioning and take up higher levels of radioiodine and appear as hot nodules.
Found that 4% of hot nodules harboured malignancy, irrespective of radioiodine image findings. Therefore carcinoma cannot be excluded following radioiodine scans
What is the single most important factor in the prognosis of a thyroid cancer?
Age
What are the other prognostic factors on which most of the thyroid cancer staging system are based?
Extra thyroid invasion (T4)
Distant metastases
Tumour size (>4cm)
Histological grade (follicular histology=poor)
What are the indications for thyroid surgery in thyroid cancer?
Malignancy on needle aspiration, with airway compromise, or a mass suspicious of malignancy are candidates for surgery.
What are the indications for thyroid lobectomy?
LOW RISK PAPILLARY CARCINOMA Unifocal, Non-metastatic papillary carcinomas Less than 1.0 cm in diameter No previous exposure to radiation A clinically normal contralateral lobe.
What surgical intervention do most thyroid cancer patients recieve?
Total thyroidectomy
+radioactive iodine ablation
+thyroid suppression therapy.
(The regional lymph nodes need to be addressed and the appropriate neck dissection performed]. This allows serum thyroglobulin levels to be used to monitor patients following total thyroidectomy).
Describe the follow up following total thyroidectomy?
A diagnostic radioactive iodine scan is performed at 6 week post-surgery. Radioactive iodine ablation is used if any residual thyroid tissue is present.
Scans need to be repeated annually and serum thyroglobulin used as a marker hence why (regional LN’s removed) with regular neck examination.
What is the surgical role in anaplastic cancer?
External beam radiotherapy and/or chemotherapy are used for palliative purposes.
Nitinol airway stenting is useful with laser to maintain the airway in a palliative setting.
A tracheostomy may be useful to maintain the airway.
What is the surgical role in medullary cancer?
Patients are best treated by total thyroidectomy and central lymph node clearance.
Thyroxine replacement is given post-operatively and calcitonin is a useful marker for follow up.
What are the complication of total thyroidectomy?
The cervical neck scar a lot of time to fade, is the complication that concerns patients most.
1%-2% risk of damage to the recurrent laryngeal nerve resulting in hoarseness.
The external laryngeal branch of the superior laryngeal nerve may cause dysphonia if injured.
Damage/removal of parathyroids may cause transient or permanent hypocalcemia.
Haemorrhage results in respiratory compromise, it is potentially life threatening.
This complication occurs in 2% of patients.
Give an example of recent surgical advancement in thyroid care?
Endoscopic thyroidectomy is being developed due to its superior cosmetic results diminished pain and the added benefit of requiring a shorter hospital stay.
