MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU
„TVOŘÍME BUDOUCNOST MEDICÍNY“
Oncology in ENT I
KOCHHK FNUSA
Clinic of Otorhinolaryngology and Head and Neck Surgery, Masaryk
university, Faculty St. Ann Hospital
Head: Ass. Prof. Gál Břetislav, MD, Ph.D.
Pekařská 53
656 91 Brno, Czech Republic
Incidence
Malignant tumors of head and neck represent in men
approx. 6 %, in women approx. 2 % of all malignant
tumors.
In CR incidence of ca orofarynx and oral cavity 12,7/100
000 in man and 4,6 /100 000 in woman (2012);
increasing trend.
Incidence of larynx carcinoma was in CR 9,3/100 000
inhabitants in men and 1,1/100 000 inhabitants in
women (2012).
Incidence partially depends on geographical site (increase
from North to South)
Development of head and neck cancer
incidence in CR
Zdroj: Národní onkologický registr, ÚZIS ČR
0
1
2
3
4
5
6
7
19771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005
Početnovědiagnostikovanýchnádorů
na100000osob
Lip and oral cavity
(C00, C02-C06)
Oropharynx, hypopharynx
(C01, C09-C10, C12-C14)
Epipharynx
(C11)
Salivary glands
(C07-C08)
Larynx
(C32)
Paranasal sinuses (C30-C31)
Therapeutic results of Head and Neck
Cancer in relation to stage
Approximate 5-year survival
I. stage 91 %
II. stage 77 %
III. stage 61 %
IV. a 32 %
IV. b 25 %
IV. c 4 %
The prognosis of patients with the head and neck carcinomas is worsened due to
frequent associated diseases. (hepatic cirrhosis, diseases of circulatory and
breathing systems etc.).
Aim of clinical diagnosis
Determine
• Verification of malignancy; determination of
character (grading) and size of primary tumor,
staging. The result is TNM classification.
• determination of performance status of organism,
incl. psychological and social status.
• Complete history of disease
• Clinical examination - inspection, palpation incl. endoscopy
• Histology of primary tumor, lymphatic drainage (FNAB, FNAC),
cytology diagnosis (HPV)
• Diagnostic imaging – CT, MR of the neck, X-ray of chest, better CT,
sonography of abdomen; contrast imaging of esophagus, ev.
endoscopy in case of dysphagia; PET-CT, PET-MR
• Functional examination: swallowing, phonation, breathing,
• Stomatology examination; Nutritive screening
• Exclusion of duplex tumors: prostate in man, gynecology in woman
• Special examination, if necessary: psychologic examination, social
status and support, prevention (smoking)
Clinical diagnosis, assessment of
prognosis
History of disease - „Listen to patient, he is
saying diagnosis“
HNSCC tumors (exception of glottic cancer) – some months
without specific symptoms (as civilization disease – chron.
pharyngitis, rhinosinusitiss, laryngitis), later:
• Feeling of foreign body in pharynx, burning, pain, especially
one-sided in swallowing spreading into ears, foetor ex ore
• dysphagia, limited movability of tongue, worse
pronunciation – mumbling due to tongue fixation
• anorexia, cachexia
• bleeding
• trismus
• Impaired nose breathing, epistaxis, external deformities in
face
• hoarseness, cough, dyspnea
• tumor on external neck
Aspection
Remove removable tooth prosthesis, consider pathological changes on
mucous membrane, asymmetry changes in oropharynx
• non healing damage on mucous membrane
• hard tumor covered of mucous membrane, later disintegration into
ulcer.
• exophytic tumors – patient frequently notices itself
• white and red stain persisting on palate, tongue, buccal mucosal
membrane – necessary biopsy and watching.
• neck tumor
Palpation (+bimanual palpation)
• form and size in cm, site (localization), topographic description
• consistency - soft, elastic, fluctuant, firm or hard
• mobility - vertically or horizontally, fixed or adherent
• evaluation of borders of tumor
Imaging methods
• CT, MR of the neck, X-ray of chest, better CT,
sonography of abdomen
• PET-CT, PET-MR in advanced stages of pts. with
assumption of curative treatment
• contrast imaging of esophagus, eventually
endoscopy in case of dysphagia
Undesirable side affects – CT: Radiation, MR: Small amount of Gadolinium could be stored in brain
M-classification: M0 no proof for distant. meta,
M1- exist proof for distant metastesis
thyroid gland cancer – metastases in ling M1 (PUL)
Endoscopic evaluation („optic biopsy“)
• Horizontal – NBI, SPIES (Storz Professional Image
Enhancement System – changes of color
spectrum of tissues)
• Vertical - Optical coherence tomography (OKT), radiation
similar to infrared light penetrating 1-3
mm into depth; images issues in vertical section
Arens C, Betz C, Kraft, Voigt-Zimmermann: Narrow band imaging for early diagnosis of epithelial
dysplasia and microinvasive tumors in the upper aerodigestivetract. HNO [01 Jan 2017, 65(Suppl
1):5-12] Type: Review, Journal Article. DOI: 10.1007/s00106-016-0284-x (PMID:27878600)
Classification of intraepithelial capillary
vascular loops
The highest changes of vascular microarchitecture, the
most significant probability of malignancy.
Narrow band imaging
Indication
• screening – early diagnosis
• Follow up after oncology treatment
• During evaluation or surgery for aimed biopsy
Limitations
• stagnation of saliva, mucous
• hyperkeratosis
• Influence of age, gender, lifestyle
• False positivity – laryngeal papillomatosis
Classification of intraepithelial capillary vascular
loops in esophageal tumors. Inoue – progressive
loss of vascular microarchitecture
Classification of SCC oral cavity. (Shibahara et al. 2013)
Quality of life (QOL)
• Endeavor to safe and improve. QOL is possibly limiting factor for oncologic
treatment.
• Measurement of QOL – Karnofski scale, ECOG performance status
• Measurement of QOL after oncologic treatment - psychometric
questionnaires (Quality Of Life Questionnaire), for inst. QLQ-C30, QLQN&N37
a QLQ-H&N35
Karnofski scale
Possibility of improvement of
therapeutical results
• preventive programs aimed on risk groups (smoking,
alcohol, etc.)
• earlier detection – increased oncologic „vigilance“ of
family doctors and specialists
• new methods of treatment – new
chemotherapeutics - new drugs, new protocols,
immunotherapy, gene therapy, irradiation - new
regimens, new methods in surgery
• suitable individual adaptation of current therapeutical
procedures prognostic factors should be found – for
instance evaluation of proliferation, apoptosis, DNA
ploidy
Prognostic factors
▪ In relation to patient ( Age, tobacco use, alcohol abuse,
the whole status of organism, Immunology)
▪ In relation to treatment (tumors responding better to
neoadjuvant treatment have better prognosis and they are
suitable for treatment damaging genome (chemo,
radiotherapy)
▪ In relation to disease
Prognostic factors in relation to disease
• primary localization
• TNM stage - TNM classification of malignant
tumors, International Union Against Cancer (UICC)
• serum tumor markers (CEA, SCCA, TPA, CYFRA-21-1)
• Histologic differentiation („grading“ according to
Broder)
• Predictive biomarkers
Biomarkers
Help to identify high-risk patients who may benefit from
a more aggressive treatment approach.
Help to identify patients who are resistant to
radiotherapy or chemotherapy, potentially avoiding
the morbidity of ineffective therapies.
May serve as targets for biologic therapies.
Hanahan D, Weinberg RA: The Hallmarks of cancer. Cell 100:57-
70, 2000. (8496 citations)
c-erb-B1 (EGFR)
c-erb-B2 (Her2/neu)
c-erb-B3,4
p53
p21
P16
Cyclin D1
Bcl-2, Bcl-X
BAX
MMP-9
E-cadherin
I-CAM
CD34
VEGF, bFGF
IL-8
Evasion of programmed
cell death
Inhibition of growth
inhibitory signals
Tumor invasion
and metastasis
Angionenesis
Immortalization
Aquisition of autonomous
Proliferative signaling
Telomerasis
Targeted therapy,
Precise therapy
• Higher expression of EGFR in 70-100 % HNSCC
• Blocking of signal pathway
• Activation of ADCC (Antibody-Dependent Cellular
Cytotoxicity)
• Activation on complement depended cytotoxicity
• Dependence of outcome on genetic alterations
Precise therapy include mainly genomic aspects in
diagnosis and treatment.
Signal
pathway of
EGFR in
carcino-
genesis
Mechanism
of efect
inhibitors
EGFR
• More targeted antitumor
therapy and lower
undesirable effect than
CHT
• EGFR receptors not
present in
hematopoietic tissue,
but are present in
skin, liver and GIT.
• Consequence of this
are undesirable effect:
diarrhea, rash,
hypomagnesemia
Rash, 14 days after end of therapy (RT+Cetuximab)
Addition of p-16/HPV status to evaluation of
existing markers could be very helpful in prediction of
treatment outcome in oropharyngeal cancer.
Prevalence of HPV positivity is given about 60% in Czech
population.
Checkpoint inhibitors – part of
multimodal treatment
PD-1, PD-L1 (nivolumab, pembrolizumab) a CTLA-4
inhibitors: (ipilimumab)
Immune-oncology
Independent risk faktor for survival!
Increasing Time to Treatment Initiation
Growth from a tumor of 1 g (the minimum size detectable) to a
potentially lethal mass of 1 kg requires only 10 further doubling of cell
number (DeVita: Cancer)
Colin T. Murphy, Thomas J. Galloway, Elizabeth A. Handorf, et al.:
Survival Impact of Increasing Time to Treatment Initiation
for Patients With Head and Neck Cancer in the United States. J Clin Oncol
34:169-178. © 2015
51,655 pts with HNSCC. Number of days from diagnosis to treatment
initiation 61 to 90 days compared with less than 30 days independently
increased risk of death (Cox regress analysis, HR, 1.13; 95% CI, 1.08 to
1.19)
Theory vs.
reality
68 y patient, teacher
1/2018 pain in neck
2/2018 GP gave antibiotics
20/4 2018 evaluated on ENT
Taken sample - cT4 cN3 M0, p16 +
11/6 2018 supposed onset of CHRT
TNM classification
▪ Developed by Pierre Denoix v years 1942-1952; 2017 - 8. edition
▪ Separately assessment of primary tumor (T), local metastasis (N) and distant
metastasis (M)
▪ Basic philosophy – more advanced tumor, worse prognosis
Aims:
1. Helps clinician in treatment planning
2. Give information about prognosis
3. Helps in describing treatment outcomes
4. Make easier exchange of information between treatment centers
5. Helps in research HNSCC in man
6. Support activities in fight against malignant tumors
8th edition
of TNM classification
• Published in December 2016, Czech edition
4/2018.
• Main change in comparison with 7. ed. Is
separate classification of p16+ oropharyngeal
cancer
HNSCC therapy
▪ Curative – induce permanent remission
▪ Palliative – to stop tumor growth
▪ Symptomatic (Best Supportive Care, BSC) – treat only symptoms
(pain food income, bleeding, breathing)
Localized HNSCC– separate treatment only surgery or radiotherapy
(not systemic treatment as a „definitive“ treatment)
Surgery
• Curative – complete removal of tumor tissue (R0 resection)
• Palliative – to reduce tumor mass and improve usage of other
treatment options.
Chemotherapy – only in combination with radiotherapy
Organ saving protocol
• The aim – preservation of the organ and its function
• Surgery is avoided or minimalized
• Organ preservation should not sacrifice length of
survival
• Indication: patient with locally advanced but
resecable tumor
Criterion for Treatment choice
Overall survival, time to recurrence or progression
versus
QOL, functional status, age of patient and his wish
▪ Patients with tumor penetrating cartilage are usually not
suitable for organ saving protocol
▪ Cost effectiveness
▪ Predictive biomarkers
▪ Neoadjuvant chemotherapy – tumor response to treatment
– only in clinical experiment
Treatment choice
Non surgical treatment (Chemo – radiotherapy)
• higher S-phase fraction (of cell cycle, SPF)
• Lower share of cells with realized proliferation
• Relatively good general condition (KI, BMI, weight loss)
Surgery
• Combination of higher apoptotic threshold (higher expression of
p53, bcl-2) and lower share of cells in SPF and higher share of
cells G2M phase
• Advanced tumors (higher tumor volume),
• Lower expression of Ki-67
• lower micro vascular density (hypoxic tumor)
Clinical stage
I a II
Clinical stage
III a IVa,b
Clinical stage
III a IVc (M1) +
recurrences
Surgery Radiotherapy Resectable
disease
Unresectable
disease
Organ saving protocol,
non-surgical treatment
Chemo-radiotherapy
Chemoradiotherapy
or RT + cetuximab or
radiotherapy event.
salvage surgery
Cancer of oral cavity,
oropharynx,
hypopharynx and larynx
Surgery+ RT (CHRT)
Another treatment
possibilities
The treatment strategy is usually is based on international guidelines, such as NCCN.
Nowhere in the whole world doesnt´exist unambiguous consent
regarding choice of the treatment modality. NCCN Guidelines distinguishes various
levels of consensus.
Treatment choice
The methods of surgical treatment
of lymph node metastases
Surgery from external approach – in case of primary
surgical treatment, combined with
Radiotherapy/radio chemotherapy
Non surgical treatment – in case of „organ saving
protocols“ - Radiotherapy/radio chemotherapy
The methods of treatment
Prescalene node biopsy (Daniels operation)
The radical curative neck dissection (Resectio venae jugularis
internae en bloc sec. Crile 1906) - the upper boundary of the
operation is the base of the skull and the lower boundary
lies at the level of the clavicle. The sternocledomastoid
muscle, the internal jugular vein are removed.
The goal of neck dissection is complete removal of lymph
nodes and vessels between the superficial and deep
cervical fascia.
Functional deck dissection- the sternocleidomastoid muscle,
the internal jugular vein, the accessory nerve are
preserved.
An elective neck dissection is a neck dissection carried out in
the absence of palpable lymph nodes for a primary tumor
which experience has shown to have a high metastatic
rate - oropharynx, hypopharynx, supraglottic larynx, the
base of the tongue. The purpose of this operation is to
deal with micro metastases.
Types of neck dissections
(classification according to Ferlito)
ND (neck dissection)
L (left,) or R (right,) – side of neck dissection
removed region lymph nodes, described with Roman numeral to VII, in increasing order
removed non lymphatic structures
Examples:
ND (R, I-V, SCM, IJV, CN XI) – Radical neck dissection
ND (L, I-V, SCM, IJV, CN XI, CN XII) - extended Radical neck dissection with removal of n. hypoglossus
ND (I-V, SCM, IJV) – Modified radical dissection with saving n. accessorius (n. XI)
Abbreviations: ND – neck dissection , SCM – m. sternocleidomastoideus, IJV – v. jugularis interna,
CN XII – n. hypoglossus, CN XI, SAN – n. accesorius (spinal accesory nerve), ECA – a. carotis externa, ICA – a.carotis
interna, CCA – a. carotis communis, CN VII – n. facialis,
CN X – n. vagus, SN – neck sympaticus, PN – n. phrenicus, SKN –skin,
PG – glandula parotis, SG – glandula submandinbularis, DCM – deep cervical muscles
Radical neck dissection
ND (R, I-V, SCM, IJV, CN XI) sec. Crile
Modified radical dissection with saving n.
accessorius(I-V, n.XI saved)
Prevention
Therapeutic results of Head and Neck Cancer reveal strong
dependency in relation to stage – therefore prevention!
Primary – to prevent tumor formation by influence risk
factors
Secondary – diagnosis of early tumor stages
Tertiary – early detection of local recurrences or distant
metastasis or possibly tumor duplicity
www.makesensecampaign.eu
European campaign focused on
secondary prevention
Schema of preventive evaluations,
tertiary follow-up
• Regular clinical evaluations
1st year : monthly
2nd year : every 2 months
3rd year : every 3-4 months
further years : every 6- 12 months
• Additional evaluations: X-ray examination of lungs/1 year ,
ultrasound of abdominal cavity/1 year, blood account +
screening á 3 month, CT individual. After 3 years the intervals
are protracting.
Tumors of nose and paranasal sinuses
Malignant melanoma of the nose
Carcinoma
maxillae (T4)
Incidence, Symptoms
• Incidence – less than 1% of all malignant tumors
• Usually 6-12 months without clinical symptoms,
• then unilateral nasal obstruction, small bleeding from
the nose, frequently picture of inflammation of
maxillary sinus, discharge, foetid secretion.
• In advanced tumors headache, signs of invasion of
neighboring tissue – eye, cheek, regionally
lymphadenopathy…
Etiology
Risk factors: hard wood dust, Nickel, isopropyl
alcohol, thorotrast, yperit and other
Malignant melanoma of
the nose
Investigation
▪ Rhino - endoscopy biopsy
▪ CT/MR of paranasal sinuses
▪ Investigation for exclusion distant metastasis : X
ray of lungs, Ultrasonography of organs of
stomach cavity, mamma in women and
gynecology, prostate at men, PET.
▪ stomatology evaluation
Cancer of nose and paranasal sinuses TNM
classification
Öhngren´s plane (UICC)
T1. Tumour limited to the mucosa with no erosion or destruction of bone
T2. Tumour causing bone erosion or destruction, including extension into hard palate and/or …
T3. Tumour invades any of the following: bone of posterior wall of maxillary sinus,
subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
T4. Tumour invades any of the following: anterior orbital contents, skin of cheek, pterygoid
plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses orbital apex, dura,
brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve V2,
nasopharynx. clivus
Cancer of hard palate
Therapy
Surgical treatment is preferred.
St. I, II – surgery (no risk factors present)
St. III,IV – surgery + radiotherapy (+- adjuvant
chemotherapy).
+ surgery for locoregional lymphnodes – only in
their CT or MR positivity
Surgical approaches
▪ Transfacial Lateral rhinotomy with various
modifications enabling approach to both partial and
total maxillectomies. (Weber-Ferguson)
▪ Endoscopic – benign tumors, inverted papilloma,
carcinomas – CAS (computer assisted surgery)
▪ Sublabial rhinotomy ( „midfacial degloving“) small tumors of
anterior wall of maxillae
▪ Combined craniofacial – intracranial spread of tumor +
neurosurgery bicoronar section
Surgical therapy – external
approach
▪ Maxillary sinus – parcial or total maxilectomy.
▪ Ethmoid sinus - external ethmoidectomy sec. „Moure“
▪ Frontal sinus classical rhinosurgery - Jansen- Ritter, Riedel,
Killian.
▪ Sphenoid sinus - sphenoidectomy via sublabialis,
transseptalis.
Lateral rhinotomy Weber-
Ferguson
Maxillectomy according to Memorial
Sloan Kettering Cancer Center (Spiro
1997)
▪ „limited“ maxillectomy – every maxilectomy with
removal only one wall of antrum Highmori
▪ „subtotal“ maxillectomy – removal of at least two
walls of antrum Highmori
▪ „total“maxillectomy – all maxilla is removed
Midfacial degloving
Cancer of maxillary sinus
▪ Very late diagnosis
▪ Treatment
worsening quality
of life
Surgery of cancer of paranasal
sinuses
Multidisciplinar approach
(otorhinolaryngology, plastic surgeon, neurosurgeon,
stomatosurgeon)
▪ Phase of resection
▪ Phase of reconstruction
Phase of resection
▪ Resection of primary tumor
T1, T2 – limited or partial maxillectomy
T3, T4 - total maxillectomy, extended total
maxillectomy, exenteration of orbitae
▪ Revision of parapharyngeal space (N0), neck
dissection (N>0)
Phase of reconstruction
▪ Microsurgical flaps
(in one surgery)
▪ prosthetic solution
– obturatos and epithesis
– tooth prosthesis
– eye prosthesis
Prosthesis after surgery – covering
defect
Closing the defect - vessel
microsurgery
▪ m. latissimus dorsi, m. serratus
ant. - Muscle – skin flap
▪ China flap - Skin + subcutaneous
flap
▪ Bone-muscle- flap
Ca spinocellulare maxillae l.dx.
cT4
Month after surgery
Skin used for
reconstruction of the orbit
Skin used for palate
reconstruction
Měsíc po operaci
Kůže použitá pro
rekonstrukci patra
Kůže použitá pro
rekonstrukci
orbity
Reconstruction in one step
+ Enabling sufficient radicality
+ Shorter healing after surgery
+ better cosmetic effect
- difficult possibility of detecting
recurrences in operating cavity
Survival of patients with malignant
tumors of nose and paranasal sinuses
60. year old patient JV
• Nasal polyposis for years
• 9/2009 oedema of right eye, blocked nose, without
diplopia
• Tumor adhering to dura mater
• Histology: not differentiated carcinoma karcinom. pT4b
N0M0
14.10.2009 Exenteratio orbitae l.dx, resectio maxillae partialis
l.dx, resectio baseos fossae cranii anterior, ethmoidectomia l. utr.,
transplantatio durae matris fossae cranii ant. l.dx., recontructio
defectus plastica cum musculus latissimus dorsi
Neurosurgery – resetion of dura
mater, replaced by synthetic
dura
Defect closed with musculocutaneus flap
from m. latissimus dorsi microsurgical
anastomosis on v.a a. facialis
Overall survival – 8
year, good QOL
▪ 2009 – Adjuvant CHRT
▪ Fololow up by NMR/ CT
▪ 11/2012 swelling of head on contralateral side sinusitis
frontalis a etmoidalis with periorbital
swelling
▪ Histology middle turbinate: Chronic inflammatory
changesd, withou tumor
▪ Exitus letalis - 11.4.2017 low diff. ductal
adenocarcinoma of head of pancreas
Carcinoma
maxillae (T4)
Ca spino maxillae
pT4 N0 M0
Cancer of pharynx
Cancer of epipharynx(C 11) TNM
classification
T1. Tumour confined to nasopharynx
T2. Tumour extends to soft tissues
T2a. Tumour extends to oropharynx and/or
nasal cavity without parapharyngeal
extension*
T2b. Tumour with parapharyngeal extension*
Cancer of epipharynx(C 11) - TNM
classification
T3 Tumour invades bony
structures and/or
paranasal sinuses
T4 Tumour with intracranial
extension and/or
involvement of cranial
nerves, infratemporal
fossa, hypopharynx, orbit,
or masticator space
N – Regional lymph node
(nasopharynx)
NX Regional lymph nodes cannot be assessed
N0 regional lymph node metastasis
N1 Unilateral metastasis, in lymph node(s), 6 cm or less in
greatest dimension, above the supraclavicular fossa
N2 Bilateral metastasis in lymph node(s), 6 cm or less in
greatest dimension, above the supraclavicular fossa
N3 Metastasis in lymph node(s) greater than 6 cm in
dimension or in the supraclavicular fossa
N3a. greater than 6 cm in dimension
N3b. in the supraclavicular fossa
Note: Midline nodes are considered ipsilateral nodes.
Cancer of epipharynxinvading roof,
extending into torus tubaris – T2
Ca epipharyngis
T4N2c
53 year, random finding, hypacusis
mixta. dx.
Ca epipharyngis
T4N2c
the same patient
Tumors of epipharynx- histologic
findings
• Carcinomas (WHO classification) –
• Type 1 – carcinoma spinocellulare with keratinisation
• Type 2 – carcinoma spinocellulare without keratinization
• Type 3 – low differentiated or undifferentiated carcinomas
• Tumors of soft tissue: Juvenile angiofibroma,
paraganglioma (chemodectoma).
• Malignant lymphoma
• Miscellanea: melanoblastomas, chordomas,
craniopharygneomas, neuroblastomas
Lymphoepithelioma of epipharynx
(Schmincke- Regaud)
Nasoharyngeal tumors etiology
Food habits: salt fish (nitrosamins), croton oil –
promotors of some lymphoblastic clons virus
Epstein Barr (EB virus)
Symptoms
▪ Ear – sensation of fullness in ear, worsening of hearing,
tinnitus, pain in the ear
▪ Nose - obstruction, bleeding
▪ Pharyngeal - sensation of foreign body
▪ Eye - diplopy, ophthalmoplegia
▪ Neurologic - trigeminal hypesthesia,
▪ Trotter trias: trigeminal neuralgia, hypacusis conductiva,
asymetry of soft palate from paresis on involved side.
Clinical finding: bumpy, exulcerated, rough, mostly exophytic
tissue in epipharynx
Ca epipharyngis
T4
Therapy
▪ Cancer, current protocol: Curretage of epipharynx
+ concomitant chemoradiotherapy. 55 - 70 Gy.
Eventually neck dissection (in case of persistence
arter CHRT)
▪ Lymphomas radiotherapy 40-45 Gy.
Oral cavity anatomic
sublocalisations
▪ Lips
▪ Mucosa membrane of lips and cheek
▪ Retro molar region
▪ Bucoalveolar sulcus
▪ Superior alveolus and gingiva
▪ Inferior alveolus and gingiva
▪ Hard palate
▪ Tongue before papillae circumvallate
▪ Base of oral cavity
TNM classification
▪ TNM – borders 2cm -4 cm, infiltration of corticalis ane
deep muscles of tongue
▪ Important – thickness of tumor– even in clinically
negat. neck in tumor more than 5mm thick neck
dissection necessary
▪ Infiltration of bone - T4
▪ Reconstruction with help of tongue or cheek flaps or
soft palate or microsurgery flaps
Laser surgery of
tongue
Laser
surgery of
tongue
Cancer of oropharynx
what we knew
Cancer of pharynx and larynx were
considered to have the same
cause - smoking…
what we have learnt
Many of epidemiologic studies of
molecular pathology document, that
human papillomavirus (HPV),
especially type 16 is etiologically
connected with oropharyngeal cancer
▪ Gillison 2009
HPV and prognosis of
OSCC
Prognosis of HPV related cancer is
better than tobacco related cancer.
Expression of p16 in HNSCC marked
group of HPV induced tumors with good
prognosis
Treatment of HPV positive OSCC
✓Organ saving strategy should be more
successful.
✓Better response on induction chemo and
chemoRT
Fakhry J Nat Inst 2008: 100, 261
HPV+ HPV Incidence
↑ ↓
Age <50 50-70
Risk factors oral sex smoking, alcohol
Histology low differentiated, nonkeratinizing, bazaloid middle to good differentiated, keratinizing
Markers p16 p53
TNM klassification Lower T N++ higher T N+
Metastasis in
lymphnodes cystic more homogenous
Chemoradiosenzitivity high lower
Prognosis good worse
OS (5 let) >80% < 40-50%
Comparison of HPV+ a
HPV- tumors
Tumors of oropharynx symptoms
At least half year without clinical symptoms:
▪ Painful dysphagia
▪ Pain in the ear
▪ Feeling of foreign body in the pharynx
▪ bleeding
▪ trismus
Clinical finding: hard knot covered with mucose
membrane (induration of the tonsil), later
ulceration, oral fetor. Important – unilateral
changes, palpation !
Ca spino palati mollis cT2-3 cN2b M0 st. IVa
histology: low
diferentiated
nonkeratinising
squamocelular
cancer
p16 negative
MKN: C051
MKN-O:
M-8070/3 3
Retromolar trigonum cancer T2
Ca spino palati molle T1
Left tonsil cancer
Cancer of oropharynx – soft palate IV. stage
Cancer of the base of the tongue
Tumors of oropharynx TNM
classification
T1. Tumour 2 cm or less in greatest dimension
T2. Tumour more than 2 cm but not more than
4 cm in greatest dimension
T3. Tumor more than 4 cm in greatest dimension
T4a. Tumor invades any of the following: larynx
deep/ extrinsic muscle of tongue (genioglossus,
hyoglossus, palatoglossus, and styloglossus),
medial pterygoid, hard palate, and mandible
T4b. Tumor invades any of the following: lateral
pterygoid muscle, pterygoid plates, lateral
nasopharynx, skull base; or encases the carotid
artery
Therapy of oropharyngeal cancer
Radically resected tumors
Radical surgery (safe margins, R0) + neck dissection+
actinotherapy vs. Primary nonsurgical treatment
Actinotherapy LD 55-60 Gy + boost 10-15 Gy +
chemotherapy in risk factors, always prophylactic lymph
node actinotherapy.
Lymphomas 40-45 Gy.
Advanced not radically resected tumors
Palliative radiotherapy or chemo-radiotherapy with
attempt of curative treatment or only BSC
Routes of access for
tumors of the mouth and
pharynx
Transoral(1)
• Limited indications – small accessible tumors
External approaches saving mandible
(3-5)
• Lateral pharyngotomy
• Suprahyoid median pharyngotomy
External approaches with
mandibulotomy (-ectomy) (2)
• Lateral pharyngotomy with removal of
mandibular angle
• Trans mandibular buco-pharyngectomy
(BPTM)
• BPTM with resection o lateral mandible
segment
Ca spino gingivae of mandibulae left –
pT2N2bM0. Partial mandibulectomy
without discontinuance
Bucopharyngectomy