head and neck oncology and maxillofacial surgery Flashcards
oral/oropharyngeal cancer
prevalance and incidence
1200 new registrations per year in Scotland. 600 Rx in WoS. (6% of all cancers, 5% of all cancer deaths worldwide)
Increasing incidence (younger, both sexes)
90% Squamous Cell Carcinoma
Disease of deprivation
3/ 100,000 male deaths
5 year survival worldwide 46%
75% oral/oropharynx. 25% laryngeal Ca
main risk factor for oral/oropharyngeal cancer
¾ of head and neck cancers attributable to cigarettes and alcohol use.
* Synergistic (16x more likely to get SCC)
Other factors: Betel/pan, oral hygiene, diet, HIV, EBV and HPV.
Biggest risk is prev SCC (4% per year)
classic sites in oropharynx
base of tongue
tonsil
soft palate
classic sites in oral cavity
in order of prevalence
Lateral/Anterior 2/3 of tongue
Floor of mouth
Retromolar trigone
Buccal mucosa
Hard palate
Alveolus
Lip mucosa
7 red flags
URGENT REFERRAL TO MAXFAX
1) Ulcer perists (t > 2 weeks) despite removal of any obvious causation
2) Rolled margins, central necrosis (firm raised edges – concern)
3) Speckled (erythroleukoplakia) appearance
4) Cervical lymphadenopathy (enlarged (size > 1cm), firm, fixed – to skin or muscle, tethered – hard to move, non-tender, esp unilateral)
5) Worsening pain (neuropathic (nerve root pain, sharp), dysaethesia, paraesthesia)
6) Referred pain (ear, throat, mandible)
7) Weight loss (local / systemic effects – cachectic appearance, inc metabolic demands)
describe
area of shallow ulceration, pseudomembranous slough in central aspect, erythematous border, expect to feel soft (here it is a traumatic ulcer)
describe
white patch on left border of tongue, approx. 2-3cm in length and 1cm in width, not uniformly white – non-homogenous leukoplakia, rest of tongue looks normal
Refer to MaxFax
describe
lateral tongue border to ventral tongue/FOM, larger, irregular border, erytheroleukoplakia (high risk for malignant transformation when red/white patch mix)
urgent referral
describe
lesion on lateral/ventral surface of tongue, irregular, raised with depressed areas of necrosis in it (lumpy), erytheroleukoplakia
describe
attached gingivae in upper left quadrant, erytholeukoplakia, not normal, suspicion of progressive restiform leucoplakia – high malignant transformation rate
describe
EO, crusting region on lower right lip, differential dx: neoplastic process further down compared to infective (recurrent herpes simplex labialis virus), review in week time and see if resolved
describe
left oral commissure has white that enters onto buccal mucosa – raised, irregular, possible firm, suture present (biopsy taken), malignancy or chronic hyperplastic candidiasis (debatable premalignant condition) – referral to check for dysplasia
describe
left border of tongue, large area that is irregular, central ulceration, white and red patches, tongue may have limited movement, likely tender to touch
lymph nodes in neck
always examine
learn name/number as communication aid
1a – submental
1b – submandibular
2 – upper jugular chain (divided by spinal accessory nerve)
3 – middle jugular chain
4 – lower jugular chain
5 – posterior triangle (divided by spinal accessory nerve)
1a lymph node
submental
1b lymph node
submandibular
2 lymph node
upper jugular chain (divided by spinal accessory nerve)
3 lymph node
middle jugular chain
4 lymph node
lower jugular chain
5 lymph node
posterior triangle (divided by spinal accessory nerve)
describe
level 1b lymphadenopathy, oval shaped enlargement 2-2.5cm by 1cm (large than should be), angle of mandible
describe
level 2 lymphadenopathy, oval shaped approx. 4mcm by 2cm
describe
posterior triangle enlarged lymphadenopathy Va
what to check lymph nodes for
6
- Fixed
- Tethered to underlying structures
- painful
- Symmetrical (uni or bilateral)
- Firm
- If intraoral cause
inc lymphadnopathy description in referral?
yes
will be check on Ultrasound or if still unsure a fine needle aspirate of the lump
possible investagations
CT scan of primary sites, neck and thorax
* sagittal, coronal, axial views
OPT – assess dentition to see if dentally fit (remove poor prognosis) prior to radiotherapy
US Scan of enlarged node in neck – check cells of lymphadenopathy if no obv primary site (US guided FNB)
Punch biopsy
describe CT scan
Left maxilla is abnormal (different to RHS)
Loss of zygomatic buttress, maxillary sinus and subcutaneous swelling towards left cheek, possible invading ethomoidal sinus
3D
* bony window - left maxilla eaten away by pathology – likely malignant neoplasm
* vascular window – supply to tumours and recon purposes
lymph nodes on CT
yes
check for large/abnormal lymph nodes and metastases
unsure on extent of disease in theatre?
stain with Loogals iodine staining in theatre, highlights dysplastic tissue
dysplasia is associated with premalignancy – abnormal cells that can go onto to be malignant
TNM staging
T - tumour - size, depth of invasion (inc risk of metastasis)
N – nodes – involved lymph nodes in neck (number and uni or bilateral), breached extra-nodule capsule of lymph node (clinically, radiology, pathology confirmed)* ENE extra-nodal expression or ECS extra-capsular spread*
M – metastases – distant metastases, most common site for H&N cancer is thorax
tx plan process for head and neck oncology cases
- Examination
- Imaging (CT or MRI for primary site and CT Chest)
- Tissue (Histology)
- Provides a TNM staging
- Present at MDT and produce management plan
6 tx options for head and neck oncology
- Curative vs Palliative vs Best Supportive care
- Nil
- Surgery alone
- Radiotherapy alone
- Chemo radiotherapy
- Dual or Triple Modality
WHO guidance has performance status ranking which helps determine which Tx option pt can manage with
primary sites surgical options
4
- Resection and packing
- Resection and Primary closure
- Resection and reconstruction
- Local flap, pedicled flap or free flap
what are local flaps
FOM cancer edentulous and use buccal mucosa to repair
FANN flap, Pedicle flap – still attached to original blood supply rotated into area it is needed in (pectoralis major commonly used),
Free flaps – tissue is detatched with their blood supply and moved to another part of body and anstamosed to new blood supply – mainly used
why reconstruct
restore form and function
how to plan reconstruction
- Planning with 3-D CT
- +/- Model/mirror image if asymmetric tissue loss
- Cutting guides & templates
Resection Planning
* tumour in anterior mandible, invading lower lip, FOM, tongue
can create cutting guides from plans
possible donor sites for head and neck oncology
7
- Radial Forearm - common for tongue recon
- Rectus Abdominus - avoid, pneumonia post op risk
- Latissimus Dorsi - good for bulk
* Anterolateral Thigh - common for intra and extra oral lesions - DCIA - avoid, mobidity risk, hard to harvest
- Fibula - most common composite site (combo soft tissue and bone)
- Composite Scapula
multiple flaps….
inc risk and complications
Osteoradionecrosis
side effect of head and neck cancer
Necrotic bone in a previously radiotherapised field
* Hypoxia, hypocellular and hypovascualrity
Radiotherapy > 70 Gy, mandible > maxilla
* Incidence not decreasing despite IMRT
All new OSCC patients see restorative specialists
Management mainly preventative
classification of ORN
I asymptomatic exposed bone
II
III cutaneous fistulisation +/- pathological fracture
Hard to manage when progress to III
