Upper aero-digestive tract neoplasia

Section: Head and neck Curriculum: Curriculum, page 42

Locations

• Oral cavity
• Pharynx
• Larynx
• Nasal cavity
• Paranasal sinuses
• Thyroid
• Salivary glands

Epidemiology

• M>F
• Advanced age
• Geographical differences
  • Eastern countries more highly affected

Anatomy

• Oral cavity
  • Boundaries
    • Wet lip mucosa
    • Hard palate
    • Mylohyoid
    • Circumvallate papillae of tongue
    • Palatoglossus muscle (anterior tonsillar pillar)
    • Buccal mucosa of cheeks and retromolar trigone
  • Pharynx
    • Nasopharynx - posterior choanae of nasal cavity to soft palate
    • Oropharynx - soft palate to hyoid bone and pharyngoepiglottic folds (ant is circumvallate papillae on tongue)
    • Hypopharynx
  • Larynx
    • Supraglottic
    • Glottic - true VC and mucosa of ant and post commissures
    • Subglottic - to the end of the cricoid cartilage
  • Nasal cavity and sinuses
  • Salivary glands

Aetiology

• Smoking - specifically tobacco (both smoked and smokeless)
• EtOH
• HPV - oropharyngeal
• EBV - nasopharyngeal

Grouped

• Infection - EBV, HPV, HSV, Hep C, HIV (immunodeficiency)
• Drugs/diet - tobacco, EtOH, Betel nuts
• Iatrogenic - prev RTX (long latency period), oral mouthwash
• Congenital/genetic - Fanconi anaemia

Pathology

• 95% = SCC

  • Classified based on differentiation
    • Well differentiated - >75% keratinization
    • Moderately differentiated - 25-75% keratinization
    • Poorly differentiated - <25% keratinization
• <5% = other pathologies
  • Verrucous carcinoma - variant of SCC
  • Adenocarcinoma
  • Adenoid cystic carcinoma (salivary gland)
  • Mucoepidermoid carcinoma (salivary gland)

SCC

• Progression from premalignant change secondary to carcinogen exposure
  • Leukoplakia - hyperkeratosis +/- epithelial hyperplasia
    • Risk of malignant transformation <5% (without dysplasia)
  • Erythroplakia - red superficial patches adjacent to normal mucosa
    • Associated to epithelial dysplasia
    • Risk of CIS/inv tumour - 40%
  • Dysplasia - presence of mitoses and prominent nucleoli
    • Risk of transformation to inv tumour - 15-30%
• Types
  • Verrucous SCC - non HPV related
  • Basaloid SCC - tobacco
  • Spindle cell SCC

Human papillomavirus

• Causes oropharyngeal SCC
• Should be checked for all of them - aides treatment and prognostication
• Test - p16 IHC = surrogate marker

Clinical

• Site dependent
• Local sx
  • Pain
  • Bleeding
  • Mass
  • Ear pain - otalgia → CN 5, 7, 9 and 10 could be implicated
  • Nasopharyngeal - neck mass (LN), hearing loss, otitis media (serous), tinnitus, nasal obstruction, eye sx
  • Oral cavity - pain, ulcers, loose teeth, dysphagia, odynophagia, bleeding, dysarthria
  • Oropharyngeal - dysphagia, odynophagia, otalgia, OSA, snoring, bleeding, neck mass
  • Hypopharyngeal - same as above but present late and can get SOB
  • Laryngeal - hoarse voice, dysphagia, referred otalgia, cough, haemoptysis, stridor, AW obs, SOB/OE
  • Sinus - epistaxis, unilateral nasal obstruction, facial/head pain is later - tumour infiltration into bone/nerve
• Systemic sx
  • Weight loss
  • Fevers
• Relevant BG
  • Risk factors
  • Surgery
  • RTX

Examination

• Through GP H+N examination
  • Eyes, ears, nose, mouth, neck
  • All mucosal areas
• Scopes - nasendoscopy, laryngoscopy, OGD directed by sx
  • Laryngopharyngoscopy
    • Rationale
      • Second primary tumours (high risk in tobacco/EtOH/FHx)
      • Searching for an unknown primary
      • Localisation and surgical planning

Staging/Diagnosis

• Each primary tumour site has its own TNM classification…..
• FNA >90% S+S
  • Provides information about cell type NOT ARCHITECTURE
  • Use in H+N ca - cervical LN, thyroid nodules, salivary gland masses
  • If non dx and clinical suspicion - rpt and then consider excision biopsy
• Core
  • Architectural info, tumour infiltration of connective tissue, prognostic factors (PNI/LVI)
  • Can do IHC studies
• Open LN biopsy
  • Indications
    • Unable to achieve dx with FNA or core
    • Unable to safely perform FNA or core
  • Complications
    • Bleeding/haematoma
    • Nerve injury
    • Oesophageal/tracheal injury
    • Wound infection
    • Lymphoedema
    • Non-dx
• Margins
  • Clear margins on inked specimen
  • Clear = >5mm from invasive tumour
  • Close = <5mm from invasive tumour
• SNB (3 hot nodes)
  • Helps to determine what LN basins to go for with midline lesions
  • Should be considered for oral SCC <3mm and
  • If >3mm need to decided to do vs elective neck dissection
  • Alternative options are uni/bilateral neck dissection

Investigations

• CT
  • Good to assess bone involvement
  • Complete quicker
  • Thin slice 1mm
  • Regional LN
• MRI
  • Good for soft tissue information and superficial cancers
  • Distinguish tumour from mucous
  • Bone marrow invasion
  • Skull base invasion
• PET
  • Good for regional and distant mets and second primaries
  • When to consider PET
    • High risk for mets
    • Equivocal CT/MRI
    • High risk second malignancy (tobacco, EtOH, FHx) and not having scopes
    • Restaging after treatment
• Triple Endoscopy
  • Laryngoscopy
  • OGD
  • Bronchoscopy
  • Indication
    • Identify a second primary tumour
    • If primary in GIT - 2nd usually in GIT
    • If primary in larynx - 2nd usually in RESPIRATORY TRACT

Management

• MDM
• Usual + SLT, dentists, dieticians

Localised or Early Stage Disease

• Definition
  • Stage 1 or 2 - ie no LN, depends on T stage mainly!
  • T2 and less with no nodes or distant mets
• Surgery vs RTX
  • Similar outcomes - local control and survival
  • Mainstay
  • Depends on
    • Specific site
    • Surgical accessibility
    • Functional outcomes and morbidity of each modality
    • EXCEPT oral cavity cancers → Should get surgery!
  • RTX
    • External beam vs brachy
    • Options
      • Definitive - i.e. without surgery
      • Adjuvant (+/- chemo)
        • Indications
          • Pathologically locoregionally advanced
          • Close or positive margins
          • PNI
          • LVI
          • ENE
          • Multiple positive LN on elective LN dissection on clinically N0 patient
    • Minimises functional disturbance
    • Suits larynx/hypopharynx
  • Surgery
    • Reserves RTX for recurrent or sequential malignancy
    • Allows removal or primary and occult mets

Locoregionally Advanced Disease

• Definition
  • Stage 3 or 4
• Generally need surgery, RTX and chemo and orders may differ (MULTIMODAL)
• Factors to consider
  • Location of tumour
  • Patient factors
  • Functional consequences and morbidity of modalities
• If distant mets → palliative chemo
  • Cisplatin and 5-FU

Management of Neck

• H+N SCC has LN mets to cervical nodes
• If node positive and having definitive chemorad or rad up front
  • Response determines next step
  • At 6 weeks if progression - salvage neck dissection
    • If regression → give 6 more weeks then PET
      • If progression salvage neck dissection
      • If regression - clinical observation