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HNNS > HNS35 NPC And Other Head And Neck Tumours > Flashcards

HNS35 NPC And Other Head And Neck Tumours Flashcards

1
Q

Histology of head and neck

A

3 mains types of epithelium:

  1. Respiratory (main, functional, ***Ciliated Pseudostratified columnar epithelium with Goblet cells)
    - Ciliated cells
    - Mucous cells
  2. Transitional (non-ciliated epithelium)
  3. Squamous (main)
    - present where there is communication with environment i.e. Oral cavity, Pharynx, Nasal vestibule
    - ***Stratified squamous —> resistant to damage / pathogens

Main neoplasm sites: Respiratory / Squamous epithelium

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2
Q

***Cause of disease (VINDICATE) in head and neck tumours

A
  1. Vascular
    - Juvenile angiofibroma
  2. Inflammatory
    - Nasal polyps
  3. ***Neoplastic
    - Nasal neoplasms (Epithelial / Stromal / Lymphoid)
    —> Papilloma
    —> SCC
    —> Malignant melanoma
    —> Adenocarcinoma
    —> Malignant lymphoma
  • Nasopharyngeal neoplasms
    —> **NPC (SCC, Differentiated, **Undifferentiated Non-keratinising carcinoma)
    —> Sarcoma
    —> Lymphoma
  1. Degenerative (none)
  2. Infectious
    - TB, Leprosy
    - Scleroma
    - Aspergillosis, Candidiasis
  3. Congenital
    - Cleft palate
    - Choanal atresia / stenosis
  4. Auto-immune
    - Wegener’s granulomatosis
  5. Traumatic / Toxic
    - Wood dust associated adenocarcinoma
  6. Environmental / Endocrine
    - Allergic nasal polyps
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3
Q

Vascular - Juvenile angiofibroma

A
  1. Juvenile angiofibroma
    - Malformation of nasal ***erectile tissue
    - Young boys predominant —> develops around puberty and regresses afterwards
  • **Vascular + Fibrous lesion (mass/polyp)
    —> well-circumscribed, inflamed, oedematous polypoid mass
    —> can lead to **    extensive bleeding
  • Present as Nasal obstruction / ***Intermittent epistaxis
  • considered benign tumour —> but can infiltrate surrounding tissue —> extensive destruction
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4
Q

Inflammatory - Nasal polyps

A
  1. Nasal polyps
    - Rounded projections of oedematous mucous membrane
    - develop in association with Inflammation, Allergy, Mucoviscidosis (cystic fibrosis)
  • usually **Allergic in nature
    記:
    1. **    Oedematous fibrous tissue / stroma
    2. Eosinophils + Plasma cells (not as vascular as angiofibroma)
  • ***Goblet cell hyperplasia in respiratory epithelium
  • always examine histologically —> more serious diseases e.g. cancer can also present as polyps
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5
Q

Infection causes

A
  1. Tuberculosis, Leprosy
    - caseous necrosis surrounded by epitheloid histiocytes
  2. Scleroma (by ***Gram -ve bacilli)
    —> chronic bacterial infection
    —> granulomatous disease which begins in nose
    —> progressively extend into nasopharynx, oropharynx, larynx
  3. Aspergillosis, Candidiasis
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6
Q

Congenital causes

A
  1. Cleft palate (unilateral / bilateral)
  2. Choanal atresia / stenosis
    —> connection between nasal canals and pharynx is blocked completely / partially
    —> by soft tissue membrane / bony plate
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7
Q

Autoimmune causes - Wegener’s granulomatosis

A
  1. Wegener’s granulomatosis
  • ***Necrotising giant cell granulomas due to Autoimmune cause
    —> appear in URT first
    —> spread to trachea / lungs
    —> along midline
  • ***Vasculitis (no caseous necrosis)
  • Mixture of ***1. Multinucleated giant cells, 2. Histiocytes, 3. Granulation tissue
  • Untreated: death within a year
    —> associated **Renal arteritis, **Necrotising glomerulitis —> Renal failure
  • a type of **Lethal midline granuloma
    —> a syndrome of a **    non-infective destructive lesion of URT
    —> include Wegener’s granulomatosis, Conventional malignant lymphoma, Polymorphic reticulosis
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8
Q

Traumatic / Toxic causes

A

Wood dust associated adenocarcinoma

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9
Q

Endocrine / Environmental causes

A

Allergic nasal polyps

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10
Q

***Nasal neoplasms

A
  1. Epithelial
    - Papilloma
    - SCC
    - Malignant melanoma
    - Adenocarcinoma
  2. Stromal (uncommon)
  3. Lymphoid
    - Malignant lymphoma
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11
Q

Nasal neoplasms - Epithelial tumours

A

Benign:

  1. ***Papilloma (squamous / transitional) (HPV-related)
    - can recur
    - can have inverted papilloma

Malignant:

  1. ***Squamous cell carcinoma (most common)
  2. Malignant melanoma
  3. Adenocarcinoma (wood dust exposure)
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12
Q

***Nasal neoplasms - Lymphoid tumours

A
  1. Malignant lymphoma
    - 2nd most frequent **extranodal lymphoma in Chinese (1st: GI)
    - **    T cell lineage
    - **EBV-associated
    - **    Polymorphic reticulosis
    —> smaller number of ***lymphoma cells intermixed with plasma cells, histiocytes, immunoblasts, neutrophils, eosinophils
    —> polymorphous mixture
  • Untreated case —> progress into more aggressive conventional lymphoma
  • Early biopsy often mistaken for benign lesion ∵ scattered lymphoma cells
    —> obtain adequate tissue / repeat biopsy
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13
Q

***Nasopharyngeal neoplasms - Nasopharyngeal carcinoma (NPC)

A
  • common in southern Chinese
  • Males + Middle-aged
  • WHO classification:
    1. Squamous cell carcinoma (uncommon) ~ those in other parts of oropharynx
    2. Differentiated Non-keratinising carcinoma ~ Transitional carcinoma
  1. Undifferentiated Non-keratinising carcinoma (most common 95%)
    - NO squamous / glandular differentiation (no keratin / gland formation)
    - sheets of **polygonal cells / **spindle cells
    - **Tumour cells mixed with lymphoid stroma
    —> **    Lymphoid infiltrate present (prominent)
    —> ***Lymphoepithelioma (lymphoid infiltrate which is just local tissue reaction to tumour)

—> ALL have some degree of epithelial differentiation —> derived from same type of cell

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14
Q

***NPC Etiology

A
  1. Genetic factor (modest)
    - combination of HLA A2 + BW 46 —> Southern Chinese, not found in Western
  2. Dimethylnitrosamines
    - salted fish, phorbol esters in plants / oils —> mutagenic
  3. **Epstein-Barr virus
    - MOST NPCs contain EBV
    - patients have elevated serology to EBV: **    IgA component of **Viral Capsid Antigen (VCA)
    - can **    transform epithelial cells into cells capable of cell growth (capable of doing that to lymphoid cells)
  • **Additional Diagnostic tests for EBV:
    1. In-situ hybridisation
    2. Latent Membrane Protein 1 (LMP1) + Bam ARightFragment1 (BARF1) —> Oncogenic proteins produced by EBV
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15
Q

Pathogenesis of NPC

A

Normal nasopharyngeal epithelium
—> Reversible mild hyperplasia
—> Early premalignant lesion
—> Irreversible malignant transformation

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16
Q

Locations of NPC

A

Nasopharynx

  • ***fossa of Rosenmuller (Pharyngeal recess: Opening of Eustachian tube)
  • seen as ulcer / nodular area / smooth bulge / fungating mass
  • obscure area —> small and clinically silent until widespread metastases

Local spread

  • ***Parapharyngeal space —> base of skull —> through foramina —> into Cranium
  • local involvement of blood vessel, cranial nerves, lymphatics, muscles

Distal spread

  • Lymphatics —> Neck LN in head/neck —> other sites
  • Blood —> other organs
17
Q

***Signs and symptoms of NPC

A
  1. Deafness and Tinnitus
    - blockage of Eustachian tube (1st symptom)
    - can affect CN8
  2. Bleeding
    - blood in postnasal drip (excess mucus drips to back of throat) (very significant in early diagnosis)
  3. Headache and facial pain
    - caused by involvement of CN5
    - temporal headache
    - ***Corneal reflexes should be tested in suspected patients (involuntary blinking of the eyelids elicited by stimulation of the cornea —> sensory by CN5)
  4. Neck nodes
    - 1st palpable nodes: Upper jugular group at apex of ***posterior triangle (back of skull)
    - bilateral involvement in 1/3 of case
    - can also appear only on contralateral side
18
Q

Treatment of NPC

A
  1. External radiotherapy
    - Undifferentiated carcinoma response best
    - SCC least favourable
    - Recurrence is high, occur within first 2 years following completion of radiotherapy
    —> routine follow up to detect early relapses
    —> ***Plasma EBV copy number to determine relapse
  2. Adjuvant chemotherapy
19
Q

Other nasopharyngeal neoplasms / Non-epithelial neoplasms

A
  1. Sarcoma
    - after radiation for NPC
  2. Lymphoma
    - T-cell
    - associated with EBV
20
Q

Oral cavity and tongue pathologies

A
  1. Inflammatory
    - Aphthous ulcers (飛滋)
  2. Neoplastic
    - **SCC (∵ oral mucosa: stratified squamous epithelium)
    —> related to **    smoking +++
    —> other risk: viral (HSV, HPV), poor dentition
  3. Auto-immune
    - ***Lichen planus
  4. Traumatic / Toxic
    - Ulcers
21
Q

Salivary gland pathologies

A
  1. Inflammatory
    - ***Sialadenitis (inflammation of salivary glands usually ∵ obstruction by stone)
    - Mucocele (mucous cyst: obstruction of minor salivary gland by stone)
  2. Neoplastic
    - Benign
    —> ***Pleomorphic adenoma
    —> Warthin’s tumour
  • Malignant
    —> ***Mucoepidermoid carcinoma
    —> Adenoid cystic
    —> Lymphoepithelioma-like carcinoma
  1. Infectious
    - Viral: ***Mumps
    - Bacteria: uncommon
  2. Auto-immune
    - ***Sjögren’s syndrome (destruction of gland —> dry eyes + dry mouth)
22
Q

Benign + Malignant neoplasms of Salivary gland

A

Benign:

  1. ***Pleomorphic adenoma (most common)
    - different appearances within tumour
    - Epithelium forming small ducts + Myoepithelial cells
    - Stroma: myxoid / chondroid
    - Parotid gland
    - local excision for treatment: ensure CN7 is preserved
    - can get local recurrence
  2. Warthin’s tumour
    - Papillary cystadenoma lymphomatosum papilliferum / Adenolymphoma (got lymphoid stroma —> BUT NOT a lymphoma!)
    - mostly in Parotid gland
    - bilateral

Malignant:

  1. ***Mucoepidermoid carcinoma (most common)
    - combination of Squamous (epidermoid) + Glandular (muco) epithelium
  2. Adenoid cystic
    - more common in Minor salivary glands (less in Parotid gland)
    - mixture of Myoepithelial cells + Glandular cells
    - locally invasive
  3. Lymphoepithelioma-like carcinoma (common in Chinese)
    - looks like NPC
    - can be associated with EBV
    - metastasise to lungs + LN
23
Q

Larynx pathologies

A
  1. Inflammatory
    - **Vocal polyp (singer’s nodule) (most common)
    —> chronic laryngitis from mechanical injury to vocal folds (e.g. misuse of voice)
    —> Squamous **    metaplasia, Localised stromal ***edema, Degeneration
  2. Neoplastic (ALL squamous, Supraglottic / Glottic / Subglottic)
    - **Squamous papilloma (most common, associated with HPV)
    - Carcinoma-in-situ
    - **    SCC
  3. Infectious
    - Viral (influenza, adenovirus, chicken pox)
    - Bacterial (β-haemolytic streptococci, haemophilus influenzae, Corynebacterium diphtheriae) —> Acute laryngitis
    - ***Epiglottitis (H. influenzae): severe and rapidly progressive infection in early childhood —> severe oedema involving larynx —> Intubation / Tracheostomy required apart from antibiotic
  4. Congenital
    - Laryngeal web: thin and translucent membrane spreading between vocal folds near anterior commissure
  5. Auto-immune
    - Bee stings —> oedema
  6. Traumatic / Toxic
    - Burns —> oedema
24
Q

Larynx neoplasms

A

Benign

  1. Squamous papilloma (Juvenile)
    - either sex, at very young age
    - **multiple lesions covering a wide area of mucosa
    - soft, highly mobile (∵ loose / long pedicle)
    - high recurrence rate following excision but **    disappear after puberty
    - may become malignant (usually after repeated irradiations)
    - some have viral etiology
  2. Squamous papilloma (Adult)
    - **single
    - from **    vocal folds
    - need to distinguish from papillary carcinoma
    - rare recurrence
    - rare malignant change
  3. Carcinoma-in-situ
    - multicentric in origin
    - true vocal folds

Malignant

  1. Invasive SCC
    - ~70 years old (any age after childhood)
    - history of chronic laryngitis / heavy smoking
    - **hoarseness, pain, **dysphagia, ***haemoptysis
25
Q

Anatomical classification of Laryngeal tumours

A

ALL tumours

  • ***well-differentiated SCC
  • varying degree of keratin formation
  • Papillary / Ulcerative / Infiltrative
  • direct extension within mucosa, submucosa
  1. **Glottic (Vocal folds, Anterior, Posterior commissures)
    - most frequent, **    better prognosis
    - present early with hoarseness
    - confined to larynx for some time
  2. Subglottic
    - rare, worst prognosis
    - metastasise rapidly to regional LN —> Lungs
    - may remain silent until advanced stage
  3. Supraglottic
    - intermediate
    - metastasise rapidly to regional LN —> Lungs
    - may remain silent until advanced stage

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