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Head and Neck Cancer
Ⅵ Ⅵ Ⅵ
Ashok R. Shaha Snehal Patel Daniel Shasha Louis B. Harrison
ANCER OF THE HEAD AND NECK CONSTITUTES approximately 4% of all cancers in the United States, and the vast majority are squamous cell carcinomas. Generally, this disease affects the elderly and is associated primarily with long-term abuse of tobacco and with alcohol consumption. The management of head and neck tumors presents functional and esthetic problems relating to the loss of function of important structures, such as the tongue, mandible, and larynx. The results of surgery in patients with this type of cancer have been improved by such major advances as conservative or partial resections and the use of microvascular free-tissue transfer in reconstruction and by better deﬁnition of the roles of chemotherapy and radiotherapy. Despite these advances, the treatment of locoregional recurrence remains a major challenge, as success rates for salvage therapy are poor. Most patients with locoregional recurrence develop progressive disease associated with signiﬁcant suffering. Effective management of patients with head and neck cancer consists of a true multidisciplinary approach involving head and neck surgeons, medical oncologists, radiation therapists, neurosurgeons, plastic surgeons, oral surgeons, maxillofacial prosthodontists, speech therapists, nutritionists, clinical nurses, pain service, neurology service, and social workers.
TOPOGRAPHIC ANATOMY OF THE HEAD AND NECK
The major sites of the upper aerodigestive tract affected by head and neck cancer are the oral cavity, pharynx, paranasal sinuses, larynx, thyroid gland, and salivary glands (Fig. 12.1). Because they behave differently and display histologic features that are different from the other tumors in this region, tumors of the salivary glands are addressed in a separate section at the end of
Figure 12.1 Sagittal section of the upper aerodigestive tract. (Copyright ᭧ 1993 of the Massachusetts Medical Society. All rights reserved. Reprinted with permission from EE Vokes, RR Weichselbaum, SM Lippman, WK Hong, Head and neck cancer. N Engl J Med 328:184–194, 1993.)
this chapter. Tumors of the thyroid gland are discussed in Chapter 27. The oral cavity extends from the skin-vermilion junction of the lips to the junction of the hard and soft palate above and the line of the circumvallate papillae below. It is divided into speciﬁc subsites: lip, buccal mucosa, lower and upper alveolar ridges, retromolar trigone, ﬂoor of the mouth, hard palate, and anterior twothirds of the tongue (oral tongue). Usually, lymphatic drainage from the oral cavity is orderly, and metastatic spread to the neck generally occurs in a predictable and stepwise fashion. The ﬁrst-station cervical lymph nodes for anterior sites in the oral cavity are the level I nodes (submental and submaxillary), and metastasis then proceeds to levels II (upper deep cervical nodes) and III (middle deep cervical nodes). Lymphatic metastases from the tongue can involve the jugulodigastric nodes at level II or the juguloomohyoid nodes at levels III and IV directly, without involvement of the intervening levels. “Skip” metastases, however, are rare, and involvement of levels IV and V in the absence of positive nodes at more proximal levels occurs in fewer than 5% of patients . The pharynx is divided into the nasopharynx, the oropharynx, and the hypopharynx (Table 12.1). The oropharynx includes the base of the tongue, vallecula, soft palate, tonsil and tonsillar fossa, and posterior pha-
ryngeal wall. The region of the nasopharynx extends from the level above the junction of the hard and soft palate to the base of the skull. The hypopharynx includes three areas: the pyriform sinus, the posterior pharyngeal wall extending from the level of the vallecula to the level of the cricoarytenoid joints, and the postcricoid area, which extends from the level of the arytenoid cartilages to the inferior border of the cricoid cartilage. The main routes of lymphatic drainage from the pharynx depend on the site of a primary tumor: The nasopharynx drains into the nodes of the upper part of the posterior triangle, the oropharynx to nodes at level II (jugulodigastric and upper deep cervical), and the hypopharynx to nodes at levels II, III (middle deep cervical), and IV (lower deep cervical). Some primary sites (e.g., the base of tongue) have a propensity to bilateral lymphatic metastasis, a tendency common also in lesions that involve or approach the midline. Tumor (T) staging of lesions at some sites (e.g., the nasopharynx and hypopharynx) takes into account the number of subsites involved in contrast to tumors of the oral cavity and oropharynx, which are staged according to the size of the lesion, mainly because of the difﬁculty in measuring the exact extent of lesions at these sites. Anatomically, lesions of the larynx are classiﬁed as supraglottic, glottic, and subglottic. Primary tumors of the subglottic region are extremely rare (approximately
Head and Neck Cancer
Table 12.1 Subsites in Head and Neck Areas Oral cavity Lips (upper, lower) Buccal mucosa Floor of mouth Oral tongue Hard palate Gingivae (upper, lower, retromolar trigone) Oropharynx Faucial arch Tonsillar fossa, tonsil Base of tongue Pharyngeal wall Nasopharynx Posterosuperior wall Lateral wall Hypopharynx Pyriform fossa Postcricoid area Posterior wall Larynx Supraglottis Ventricular bands (false cords) Arytenoids Suprahyoid epiglottis (both lingual and laryngeal aspects) Infrahyoid epiglottis Glottis (true vocal cords, including anterior and posterior commissures) Subglottis
Source: Used with the permission of the American Joint Committee on Cancer (AJCC ®), Chicago. AJCC ® Cancer Staging Manual (5th Edition), 1997. Philadelphia: Lippincott-Raven.
1% of laryngeal tumors) in contrast to the much more common occurrence of a glottic tumor extending into the subglottis. The true vocal cord (glottis) has a very sparse lymphatic network; consequently, lymphatic metastases are uncommon. However, when glottic tumors extend to involve the adjacent supraglottic or subglottic areas, they have a high propensity to metastasize to the jugular chain and tracheoesophageal groove lymph nodes. The supraglottic larynx has a rich lymphatic drainage, and tumors of this region often metastasize bilaterally. The nasal cavity extends from the vestibule anteriorly to the nasopharynx posteriorly and from the nasal septum medially to the turbinates laterally. The middle meatus, which lies between the middle and inferior turbinates, drains the frontal, maxillary, and ethmoid sinuses. Blockage of these openings by tumor may cause symptoms of sinusitis and radiologic opaciﬁcation of the sinuses.
Cancer of the maxillary sinus is the most common paranasal sinus tumor. Other sites affected in this region include the ethmoid sinuses, nasal cavity, and sphenoid sinus. Neoplasms of the sphenoid and frontal sinuses are very rare. The maxillary antrum is divided into an anteroinferior (infrastructure) and a superoposterior portion (suprastructure) by an imaginary plane—Ohngren’s line—joining the medial canthus of the eye to the angle of the mandible. Infrastructure tumors generally are treated by partial maxillectomy and rehabilitation generally involves the use of prosthetic obturators. In contrast, tumors of the suprastructure are in closer proximity to the orbit and skull base, and their treatment involves additional considerations, including resection and reconstruction of the orbital ﬂoor and management of the eye itself. Approximately 15% of patients with tumors of the maxillary sinus will present with metastases to the regional lymph nodes at levels I (submandibular) and II (upper deep cervical). The major salivary glands are the parotid, submaxillary, and sublingual. Tumors arising in the minor salivary (mucus-secreting) glands of the upper aerodigestive tract are not staged as salivary tumors but are staged according to the respective T staging of the particular site of origin. The lymph nodes of the neck can be divided into various groups (Figs. 12.2, 12.3): preauricular and parotid group, submental and submandibular group, deep jugular lymph nodes, supraclavicular lymph nodes, lymph nodes along the accessory nerve in the posterior triangle, occipital group, and lymph nodes in the tracheoesophageal groove and superior mediastinum. The Memorial Sloan-Kettering Cancer Center classiﬁcation, which groups cervical lymph nodes into ﬁve levels (Fig. 12.4), has stood the test of time and remains anatomically relevant and clinically reproducible after more than half a century of use [2, 3]. Level I includes lymph nodes in the submandibular triangle; levels II, III, and IV are the upper, middle, and lower jugular nodes; and level V includes nodes in the posterior triangle of the neck. The nodes of the anterior compartment of the neck (prelaryngeal, pretracheal, and paratracheal nodes) have been labeled as level VI, and nodes in the superior mediastinum are designated as level VII. Over the last few decades, the management of cervical lymph node metastasis has undergone many changes. For more than the ﬁrst three-fourths of this century, the classic radical neck dissection, popularized by George Crile in 1906, was commonly used. However, with improved understanding of the anatomy and patterns of cervical nodal metastasis came the realization that routine sacriﬁce of structures not directly invaded
level III. Cervical lymph node metastasis. level V. a recent rising trend in incidence has been Figure 12. Cervical lymph node metastasis. and the internal jugular vein. J Medina. submandibular. posterior jugular. et al. and the pendulum swung in favor of more conservative operations with preservation of the uninvolved accessory nerve. and a more speciﬁcally tailored surgical procedure can be performed for individual patients in most instances.300 CLINICAL ONCOLOGY Figure 12.. approximately 500. (Reprinted with permission from JP Shah.5. Curr Probl Surg 30:273–344. et al. Cervical lymph node metastasis. AR Shaha.4 Diagram of the neck showing levels of lymph nodes. J Medina. 12.) Figure 12. Levels VI (tracheoesophageal) and VII (superior mediastinal) not shown. the sternomastoid muscle. high jugular. level II. (Reprinted with permission from JP Shah. It now is possible to evaluate the biology of the tumor and its spread. 1993. Level I. However. AR Shaha. EPIDEMIOLOGIC CHARACTERISTICS AND RISK FACTORS Head and neck tumors account for approximately 5% of the overall incidence of cancer in the United States and 2% of all cancer deaths (Figs..) by tumor does not result in better control. The routine use of postoperative radiotherapy for positive cervical node ﬁndings also affected modiﬁed neck dissections and better regional control.. J Medina. low jugular. Tumors of the upper aerodigestive tract occur mostly in the ﬁfth and sixth decades of life and predominantly affect men. Curr Probl Surg 30:273–344. 1993.6) . AR Shaha. 1993. 12.2 Anterior view of the neck showing regional lymph node groups.000 new cases of head and neck cancer are projected annually. midjugular.) . Worldwide.3 Lateral view of the neck showing regional lymph node groups. level IV. (Reprinted with permission from JP Shah. Curr Probl Surg 30:273–344. the results of surgical treatment now are judged as much by survival results as by the quality of life. et al. In addition.
Wingo PA.) seen among women.700 Tongue 2. especially in alcoholics.400 Thyroid Figure 12. Bolden S. The Plummer-Vinson syndrome. Cancer statistics. and dysphagia. 2000. especially of the tongue and oral cavity. Experimental evidence has suggested that ethanol suppresses the efﬁciency of DNA repair after exposure to nitrosamine compounds.200 Thyroid Figure 12. and southern China. Wingo PA. Cancers of the nasopharynx and hypopharynx are extremely common in Southeast Asia. 1999. (Data adapted from Greenlee RT.700 Oral cavity 3. is associated with a high incidence . 1999. Chronic abuse of snuff and marijuana has also been linked to head and neck carcinogenesis. iron-deﬁciency anemia. Cancer statistics.300 Mouth 2. The most important risk factors for this disease are tobacco and alcohol. Murray T.900 Larynx 1. patients in their third and fourth decades have presented with head and neck cancer. 2000. CA Cancer J Clin 50:7–33. Hong Kong. Approximately half of all squamous cell carcinomas of the upper aerodigestive tract occur in the oral cavity. Alcohol seems to have a synergistic effect on the carcinogenic potential of tobacco. 2000. Murray T. chewing betel nut with lime and catechu (in a quid of betel leaf called paan) is a common habit that has been associated with a high incidence of oral cancer. over the last decade.200 Oral cavity 10. Bolden S. especially of the buccal mucosa.900 Mouth 8. In India. (Data adapted from Greenlee RT.) 1.100 Pharynx 1. and approximately 80–85% of patients report a signiﬁcant history of tobacco and alcohol consumption. Oral carcinogenesis has been correlated strongly with the use of smokeless tobacco.5 Estimated number of new cases of head and neck cancer in the United States. 2000. whereas tumors of the oral cavity and base of the tongue are more common in India.100 Larynx 18.Head and Neck Cancer 301 6. CA Cancer J Clin 50:7–33. Dietary factors include nutritional deﬁciency. which includes esophageal web.6 Estimated number of deaths due to head and neck cancer in the United States.200 Pharynx 4.900 Tongue 10.
larynx. This condition is very rarely seen in the United States. The pattern of lymph node metastasis from primary tumors of the head and neck is understood better as a result of the studies conducted by Shah  (Tables 12. 1983–1987. Occupations associated with greater risk of head and neck cancer include nickel reﬁning (laryngeal cancer). on the other hand.) of postcricoid carcinoma. Genetic instability associated with the Bloom syndrome and the Li-Fraumeni syndrome has been implicated in head and neck carcinogenesis through an increase in the susceptibility of affected individuals to environmental carcinogens. HPV types 16 and 18 have been associated with a higher risk. and thyroid in the United States.5% (n=44) Localized Distant Regional Figure 12.3% (n=44) 18.9% (n=83) 39. woodworking (cancers of the nasal cavity and paranasal sinuses). liver. and viral DNA has been identiﬁed in nasopharyngeal tissue. and steel and textile workers (oral cancer). Approximately half of patients present with locally advanced disease. Mutagen-induced chromosomal fragility is an independent risk factor and correlates with the prospective development of second primary tumors. However.2. 1999. (Data adapted from Landis SH.2% (n=42) 13. Genetic predisposition to head and neck cancer has been suggested by its sporadic occurrence in young adults and in nonusers of tobacco and alcohol. Other sites of distant metastasis include the mediastinal lymph nodes.7 Distribution by stage of tumors of the oral cavity. On the basis of the most sensitive method of detection.e. an important distinction is that a solitary pulmonary nodule in patients with head and neck cancer most likely is a second primary tumor rather than metastatic cancer. 12. Murray T.8% (n=54) 45. Epidemiologic data suggest a protective role for dietary carotenoids and for consumption of fruits and vegetables. Human papillomavirus (HPV) infection also has been linked to head and neck carcinogenesis. The lungs are the most common site.302 CLINICAL ONCOLOGY Oral cavity Larynx Thyroid 29.7). Cancer statistics. NATURAL HISTORY OF THE DISEASE Although the diagnosis of most head and neck cancers is relatively easy. the overall prevalence of HPV in head and neck tumors approaches 35%.9% (n=82) 29..5% (n=94) 42% (n=100) 24. is suggestive of metastatic disease. but conclusive proof of the mechanism of carcinogenesis will require further research . Nasopharyngeal cancer has been linked strongly to the Epstein-Barr virus. The presence of multiple pulmonary nodules. especially in Europe. CA Cancer J Clin 49:8–31. A subset of patients may have genetic anomalies that increase their susceptibility to tobacco. Bolden S. only one-third of affected patients present at an early disease stage (i. along with elevated titers of IgG and IgA antibodies in affected patients . either at the primary site or in the cervical lymph nodes (Fig.3). The sites of distant metastasis from head and neck primaries are well recognized also. 1999. I or II). . 12. Increasing evidence suggests a role for viruses in the development of head and neck cancer.9% (n=20) 56. the polymerase chain reaction. Generally. such a metastatic pattern is predictable on the basis of the site of the primary tumor. Wingo PA.or alcohol-induced carcinogenesis .
but also often owing to delayed diagnosis.g.119 elective and therapeutic radical neck dissections. occasionally. A direct correlation appears to exist between the bulk of cervical nodal disease and the development of distant metastasis. Such factors as smoking and alcohol intake have a carcinogenic effect on the en- .119 34 31 17 37 33 76 84 97 84 82 303 RND ϭ radical neck dissection. Am J Surg 160:405–409. In advanced stages. even when they are huge. Some tumors may become symptomatic at an early stage. hence. Source: Reprinted from JP Shah. airway obstruction. severe dysphagia and weight loss. slurred speech. Despite these obvious and common complaints.g.081 516 213 128 262 1. as happens with tumors of the vocal cords. Note: Results for 1. malar swelling. an extremely important precaution is to rule out the presence of malignancy by the appropriate investigations and to seek expert opinion if necessary. as symptoms may be attributed mistakenly to sinusitis or allergic rhinitis. Pain. but benign tumors. Direct invasion of other nerves (e. and diplopia are common symptoms of advanced maxillary sinus tumors. chronic ulcer. lingual. Common symptoms in patients with oral cancer include painful ulceration. Patients with early nasopharyngeal cancer may present with unilateral otitis media. Patterns of cervical lymph node metastasis from squamous carcinoma of the upper aerodigestive tract.. generally is mediated by the trigeminal or glossopharyngeal nerves. and vagus and the sympathetic chain) may occur from tumors in their vicinity. 1990. high-grade parotid tumors are known to involve the facial nerve and to cause paralysis. Tumors of the nasal cavity and paranasal sinuses may remain undetected for a long time. Patients who have had radical neck dissection or radiotherapy are at increased risk of developing aberrant metastases to the neck and to subcutaneous and cutaneous sites. Synchronous and Metachronous Second Primary Tumors Patients with head and neck cancer run a substantial risk of a second primary tumor. Tumors also may spread along nerves. affected patients may neglect change of voice or minor airway distress until they present to the emergency room with acute airway obstruction requiring emergency airway intervention. In high-risk patients who present with head and neck complaints. whereas others (e. Occasionally. Occasionally. primarily because of neglect on the patients’ part. affected patients may present with acute airway distress (as described) or with intense pain. The incidence of distant metastasis varies with the primary site. brain. Hypopharyngeal neoplasms or tumors of the base of the tongue may cause otalgia mediated by Arnold’s nerve. Symptoms vary from site to site. tumors of the nasopharynx and hypopharynx are at highest risk. with permission from Excerpta Medica. the diagnosis of oral cancer is made on routine examination by a dentist or oral surgeon. CLINICAL PRESENTATION Of the several warning signs of cancer promulgated by the American Cancer Society. These symptoms may long remain uninvestigated. those of the nasopharynx or hypopharynx) may not be suspected at all. rarely do so. this route is an important consideration in planning therapy for certain tumors. Large. Inc. a relatively late symptom in head and neck tumors. Aberrant metastatic spread may occur in patients who have undergone previous treatment for head and neck cancer. such as those that invade the mandible and place the inferior alveolar nerve at risk.. Recurrent epistaxis. two of every three patients with head and neck cancer present at an advanced stage. obvious involvement of the skin of the face and neck and.081 patients undergoing 1. at least three pertain to the head and neck region: dysphagia. occasionally. of No. and lump in the neck. bleeding. the hypoglossal.Head and Neck Cancer Table 12. and an exophytic mass. Unexplained weight loss is an important ﬁnding in patients with head and neck cancer. of Elective Therapeutic Primary Site Patients RNDs RNDs (%) RNDs (%) Oral cavity Oropharynx Hypopharynx Larynx Total 501 207 126 247 1. mandibular involvement with loose teeth. the auricular branch of the vagus nerve. dysphagia. and bones.2 Distribution and Histologic Conﬁrmation of Metastatic Disease by Site Positive Positive Nodes in Nodes in No. Tumors of the oropharynx and laryngopharynx are associated with odynophagia. Advanced cancers of the oral cavity may erode through the subcutaneous tissue and skin and present with an orocutaneous ﬁstula. change of voice and. The glossopharyngeal and vagus nerves transmit pain from pharyngeal and laryngeal tumors as referred pain to the ear.
including ﬁne-needle aspiration (FNA) cytology. a patient with head and neck cancer always should remain under close observation . Meticulous history recording must include directed questions looking for such relevant speciﬁc symptoms as otalgia. Such symptoms as hoarseness of voice and sore throat must be investigated carefully. Tumors of the parapharyngeal space and the parotid also are well deﬁned using these techniques. mainly to delineate the lower limit of the lesion. examination under anesthesia and biopsy. including cancer of the lung or esophagus. An accurate histologic diagnosis is crucial for initiat- . and the use of CT and MRI reveals tumors in such difﬁcult locations as the base of the skull and base of the tongue. magnetic resonance imaging (MRI) as indicated. and salivary gland tumors. thyroid. tire surface of the upper aerodigestive tract. Diagnostic Workup The diagnostic workup in patients with head and neck cancer may include a detailed medical history and physical examination. they face an approximate 15% incidence of a synchronous second primary tumor. ultrasonography and. principally for this reason. and the like. a mirror examination. occasionally. Routine esophagoscopy and bronchoscopy probably is not justiﬁed in every patient undergoing examination under anesthesia. Some sites (e.. Patients with laryngeal and pharyngeal lesions will need a detailed endoscopic examination to map out the extent of involvement and to plan treatment. with permission from Excerpta Medica.3 Percentage of Metastatic Lymph Nodes Involved in Elective and Therapeutic Radical Neck Dissections Primary Site Level of Nodes I II III IV V Oral Cavity E (%) 58 51 26 9 2 T (%) 61 57 44 20 4 Oropharynx E (%) 7 80 60 27 7 T (%) 17 85 50 33 11 Hypopharynx E (%) 0 75 75 0 0 T (%) 10 78 75 47 11 E (%) 14 52 55 24 7 Larynx T (%) 8 68 70 35 5 E ϭ elective. Patterns of cervical lymph node metastasis from squamous carcinoma of the upper aerodigestive tract. The incidence of metachronous cancer is approximately 4% annually. Radiologic Imaging Studies The use of routine plain x-ray ﬁlms of the head and neck no longer is practiced. Ultrasonography has been used effectively in detecting lesions and in guiding FNA of small cervical nodes  and in determining carotid artery invasion by tumor . The role of ﬂuorodeoxyglucose-positron emission tomography (FDG-PET) scans in head and neck cancer continues to be investigated . T ϭ therapeutic. and nasopharyngolaryngoscopy using a rigid or ﬁberoptic scope. scalp. and gingivolabial and gingivobuccal sulci) are easily overlooked. computed tomographic (CT) scan. but patients with hypopharyngeal tumors should undergo cervical esophagus examination. and imaging studies. FNA is used Examination Under Anesthesia and Biopsy: Techniques Examination under a general anesthetic is important in evaluating patients with tumors of the base of the tongue and laryngopharynx and in patients who have oral cavity tumors that present with trismus. odynophagia.g.304 CLINICAL ONCOLOGY Table 12. and clinicians must set up a routine sequence of examination to avoid missing tumors in these sites. Source: Reprinted from JP Shah. The CT scan is very helpful also in evaluating nonpalpable cervical lymph nodes. A thorough head and neck examination includes a detailed survey of the region. Although affected patients may present at any time with one primary cancer. palpation of the neck and thyroid. 1990. and the potential for development of tumors persists even after the carcinogenic insult has ceased. symptoms that affected patients may not attribute to their disease. including a panoramic x-ray ﬁlm of the mandible. Inc. Commonly. bimanual palpation of the ﬂoor of the mouth and base of the tongue (if relevant). in the evaluation of neck masses and cervical node. nape of the neck. malar swelling. Am J Surg 160:405–409.
core-needle biopsy. because the entire capsule of the tumor must be evaluated after excision of the thyroid mass. in conjunction with cytomorphology can usually distinguish reactive lymphoid processes from non-Hodgkin’s lymphoma . (Reprinted with permission from JP Shah. FNA samples are usually processed as smears. However. the biopsy should be performed on a ﬂeshy. Needle biopsy has been popular in this country since the 1930 landmark article by Hayes Martin . This is usually not necessary if morphologic ﬁndings suggest a lymphoma. but the cup forceps is used most often. In the evaluation of cervical lymphadenopathy. FNA is now used in the evaluation of almost all head and neck masses (especially cervical lymphadenopathy ) and of thyroid and salivary tumors. FNA has become the ﬁrst-choice diagnostic test in the evaluation of a thyroid mass.Head and Neck Cancer ing correct treatment. curettage. The incisional biopsy is applied best to lesions of the skin and soft tissue or to submucosal masses in the oral cavity and oropharynx. These results. metastatic thyroid carcinoma. metachromatic nuclear stain that preferentially colors areas of squamous cell carcinoma. Various punch biopsy forceps are available. Small oral cavity lesions may be sampled easily by an excisional biopsy with satisfactory margins. The technique of FNA has been described extensively in the literature. metastatic adenocarcinoma. the fear of needle tract implantation kept it out of routine clinical use until the 1970s. Cells for the immunocytochemical or ﬂow cytometric evaluation of T. The results of FNA cytology of cervical nodal masses can 305 Figure 12. The investigation appears to be cost-effective. and every individual dealing with head and neck tumors should be conversant with the technique (Fig. a small portion of an exophytic lesion is satisfactory to make a diagnosis. However. excisional biopsy. Generally. or indeterminate. Frozen-section conﬁrmation can ensure adequate sampling and enhance diagnostic yield. In patients with diffuse areas of leukoplakia or erythroplakia in the oral cavity. If the chest roentgenogram is normal. local pressure for a few minutes is adequate to stop bleeding from the biopsy site. Biopsy of irradiated tissue always is difﬁcult because of mucosal edema and radiation changes. Copyright ᭧ 1987 by Grune & Stratton: Orlando. surface staining with such vital dyes as toluidine blue may help to direct attention to a particularly suspicious site and may improve the yield of biopsy. Usually.8) .9). can often be obtained by FNA. incisional biopsy. an algorithmic approach can be used in patients presenting with features of a malignant pathology (Fig. since classiﬁcation of most lymphomas will still require an open biopsy for routine histology. and although pathologists’ responsibility in interpreting the biopsy material is crucial. as most of these lesions can be evaluated easily in the clinic. 12. Even though the periphery of a lesion generally is the recommended site for performing a biopsy. If infection or necrotic material is present. or suspicious of lymphoma . benign. nonulcerated region of the tumor. which provide only a cytologic. The diagnoses of benign follicular adenoma and follicular carcinoma cannot be based on cytologic features alone. in certain tumors that involve . it may be useful to place a portion of the sample into a liquid preservative solution so that cell pellets obtained by centrifugation may be embedded in parafﬁn and sectioned for histologic staining. or even for molecular assays of antigen receptor gene rearrangements. 12.8 Technique of ﬁne-needle aspiration. Results of FNA of the thyroid may be interpreted as malignant. biopsies of the larynx and pharynx are performed endoscopically under anesthesia. especially for squamous cell carcinoma. perhaps equally important is the surgical technique of the biopsy. rather than histologic. suspicious. In some cases. Color Atlas of Head and Neck Surgery.and B-cell markers. Punch biopsy is the technique used most frequently for obtaining a mucosal biopsy in the head and neck. The dye is an acidophilic. so sutures rarely are necessary. such as ﬁbrosis. FL) be interpreted as metastatic squamous cell carcinoma. and its accuracy in detecting thyroid tumors exceeds 80%. detection of lung lesions is unlikely via routine bronchoscopy and selective bronchial washings. and FNA biopsy. The role of FNA in salivary gland lesions is controversial. diagnosis. Commonly used techniques include punch biopsy.
the American Joint Committee on Cancer. N2. node. FNA ϭ ﬁne-needle aspiration. the accuracy of FNA in detecting salivary lesions exceeds 80% (Table 12. Clinical correlation must be made with the results of FNA and. Am J Surg 152:420–423. in collaboration with the Union Internationale Contre le Because the upper aerodigestive tract is lined mainly by squamous epithelium. On average. Fig. with permission from Excerpta Medica.7). open biopsy Inconclusive Clinical follow-up Open biopsy Repeat FNA if necessary Hyperplasia Tuberculosis Consider open biopsy for confirmation Lymphoma Open biopsy Marker studies Electromyographic studies Met SCC Repeat H&N examination Panendoscopy/guided biopsies Neck dissection + radiotherapy Met thyroid carcinoma Thyroidectomy Modified neck dissection Met adenocarcinoma Search for primary above and below the diaphragm Chemotherapy.5). C Webber. Despite the many pitfalls of FNA biopsy of head and neck tumors. 12. Inc. metastasis) staging system for cancers of the head and neck . 1986. such as adenocarcinomas. Stage I and stage II are considered to be early cancers with a prognosis more favorable than that of advanced (stage III and stage IV) cancers. Fine-needle aspiration in the diagnosis of cervical adenopathy. FNA is very helpful in differentiating salivary from nonsalivary pathologic features. further investigation (including open biopsy) must be undertaken as appropriate. H &N ϭ head and neck. updated the TNM (tumor. J Marti. nodal disease as N1. the presence of distant metastasis is staged as M1. and the overall stage grouping consists of stages I to IV (Table 12. lymphomas.6. clearly it is one of the most important diagnostic tests available today. Cancer.306 CLINICAL ONCOLOGY Clinical history and physical examination Complete H&N examination (including fiberoptic nasopharyngoscopy) Repeat H&N examination Chest radiography FNA Benign Malignant Suspicious Decision based on clinical findings Repeat FNA.4) . Met ϭ metastatic. . Primary tumors are classiﬁed as T1 to T4 (Table 12. the most common tumors in the head and neck are squamous cell carcinomas. However. or N3 (Table 12.9 Algorithm for the management of cervical lymphadenopathy. surgery? Figure 12. Pathologic Classiﬁcation Staging System In 1997.10).) the tail of the parotid and in which a clinical diagnosis may be uncertain. (Reprinted from AR Shaha. in case of discrepancy. SCC ϭ squamous cell carcinoma. radiotherapy. other tumors.
Nettle and Orell Jayram et al.g. thyroid/cricoid cartilage. Superﬁcial erosion alone of bone/tooth socket by gingival primary is not sufﬁcient to classify as T4) Oropharynx T1 T2 T3 T4 Tumor Յ 2 cm in greatest dimension Tumor Ͼ 2 cm but Յ 4 cm in greatest dimension Tumor Ͼ 4 cm in greatest dimension Tumor invades adjacent structures (e. hypopharynx. or measures Ͼ 2 but Յ 4 cm in greatest dimension without ﬁxation of hemilarynx T3 Tumor measures Ͼ 4 cm in greatest dimension or with ﬁxation of hemilarynx T4 Tumor invades adjacent structures (e. skin.. prevertebral fascia/muscles. through cortical bone into deep [extrinsic] muscle of tongue. carotid artery. Am J Surg 160:373–376.. Inc. cavity) maxillary sinus. thyroid and/or esophagus) continued . Sismanis et al. 1990. Qizilbash et al. of Cases 690 47 51 101 461 341 171 106 195 64 160 Sensitivity (%) 64 100 85 88 67 73 91 80 81 85 95 Speciﬁcity (%) 95 95 96 100 85 94 98 99 94 97 98 307 Accuracy (%) 89 96 92 98 81 93 92 94 88 93 97 Source: Reprinted from AR Shaha.4 Effectiveness of Needle Biopsy in Detecting Salivary Lesions Authors Enroth and Zlajicek Kline et al. or orbit Hypopharynx T1 Tumor limited to one subsite of hypopharynx.. Rodriguez et al. with permission from Excerpta Medica.Head and Neck Cancer Table 12. infratemporal fossa. Յ 2 cm in greatest dimension T2 Tumor involves more than one subsite of hypopharynx or an adjacent subsite. soft tissues of neck.5 Tumor Staging of Head and Neck Tumors Classiﬁcation TX T0 Tis Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Deﬁnition Oral cavity and lip T1 Tumor Յ 2 cm in greatest dimension T2 Tumor Ͼ 2 cm but Յ 4 cm in greatest dimension T3 Tumor Ͼ 4 cm in greatest dimension T4 (lip) Tumor invades adjacent structures (e. ﬂoor of mouth. Needle aspiration biopsy in salivary gland lesions. Table 12. BM Jaffe.g. Lindberg and Akerman O’Dwyer et al.g. pterygoid muscle[s]. skin of face) T4 (oral Tumor invades adjacent structures (e. Layﬁeld et al. Year 1970 1981 1981 1985 1986 1986 1987 1989 1989 1989 1990 No. larynx) Nasopharynx T1 Tumor conﬁned to nasopharynx T2 Tumor extends to soft tissues of oropharynx and/or nasal fossa T2a Without parapharyngeal extension T2b With parapharyngeal extension T3 Tumor invades bony structures and/or paranasal sinuses T4 Tumor with intracranial extension and/or involvement of cranial nerves. Shaha et al.. deep muscle of tongue. mandible.g. inferior alveolar nerve. through cortical bone. T DiMaio. C Webber. hard palate.
g. and/or oesophagus Glottis T1 T1a T1b T2 T3 T4 Subglottis T1 T2 T3 T4 Tumor limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility Tumor limited to one vocal cord Tumor involves both vocal cords Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility Tumor limited to larynx with vocal cord ﬁxation Tumor invades through thyroid cartilage and/or to other tissues beyond larynx (e. base of skull.. the lifetime incidence of squamous cell carcinoma in an existing setting of leukoplakia is quoted as approximately 2–5%. and to keep affected patients under careful surveillance. Leukoplakia is a clinical term used to describe a white mucosal patch.g. including extension into hard palate and/or middle nasal meatus T3 Tumor invades any of the following: bone of posterior wall of maxillary sinus. leiomyosarcoma. and ﬁbrosarcoma). nasopharynx. Philadelphia: Lippincott-Raven. cribriform plate.. sphenoid. On a practical basis. soft tissues of neck. In contrast. trachea. Another important ﬁnding is that such lesions as leukoplakia and erythroplakia occur fairly frequently in patients with a history of heavy smoking and alcohol abuse. infratemporal fossa. Verrucous carcinoma is a clinical diagnosis used to characterize an exophytic tumor of wartlike appearance. ethmoid sinuses T4 Tumor invades orbital contents beyond ﬂoor or medial wall. an important precaution is to biopsy any suspicious lesions. . Histologically. trachea.g. synovial sarcoma. subcutaneous tissues. orbital extension including apex. the tumor may be so well differentiated as to cause confusion in diagnosis of malignancy. soft tissues of neck. Chicago. pharynx) Tumor limited to subglottis Tumor extends to vocal cord(s) with normal or impaired mobility Tumor limited to larynx with vocal cord ﬁxation Tumor invades through cricoid or thyroid cartilage and/or extends to other tissues beyond larynx (e.. except for posterior antral wall. preepiglottic tissues T4 Tumor invades through thyroid cartilage and/or extends into soft tissues of neck. pterygoid plates. but the actual risk of malig- nancy depends directly on the histologic presence and grade of dysplasia in the lesion. thyroid. also are seen. including thyroid. AJCC ® Cancer Staging Manual (5th Edition). including thyroid. and melanomas. skin of cheek. the incidence of squamous cell carcinoma in erythroplakia is approximately 30%. Kaposi’s sarcoma. it has no histologic meaning. medial wall of piriform sinus) without ﬁxation of larynx T3 Tumor limited to larynx with vocal cord ﬁxation and/or invades any of the following: postcricoid area.g. 1997. vallecula. especially in high-risk patients.308 CLINICAL ONCOLOGY Table 12. ﬂoor or medial wall of orbit. including any of the following: orbital apex. frontal sinuses Ethmoid sinus T1 Tumor conﬁned to ethmoid sinus with or without bone erosion T2 Tumor extends into nasal cavity T3 Tumor extends to anterior orbit and/or maxillary sinus T4 Tumor with intracranial extension. esophagus) Maxillary sinus T1 Tumor limited to antral mucosa with no erosion or destruction of bone T2 Tumor causing bone erosion or destruction.5 (continued) Classiﬁcation Deﬁnition Supraglottis T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside supraglottis (e. rhabdomyosarcoma. Generally. Rare tumors include soft-tissue sarcomas (e. involving sphenoid and/or frontal sinus and/or skin of external nose Source: Used with the permission of the American Joint Committee on Cancer (AJCC ®).. mucosa of base of tongue.
309 Table 12. but some reports cite good results with radiotherapy. 1997. Յ 6 cm in greatest dimension. Traditionally. . Prognostic factors related to the pathology of the tumor include the differentiation of the tumor. However. Chicago. A radical or modiﬁed radical neck dissection specimen should include 10 or more lymph nodes. none Ͼ 6 cm in greatest dimension.Head and Neck Cancer Table 12. Source: Used with the permission of the American Joint Committee on Cancer (AJCC ®). none Ͼ 6 cm in greatest dimension N2a Metastasis in a single ipsilateral lymph node Ͼ 3 cm but Յ 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes. Source: Used with the permission of the American Joint Committee on Cancer (AJCC ®). Anaplastic transformation of verrucous carcinoma to a more aggressive neoplasm has been reported to occur following radiotherapy. AJCC ® Cancer Staging Manual (5th Edition). inﬁltrating tumors may be associated with a prognosis worse than that of exophytic types. or perineural invasion. or in bilateral or contralateral lymph nodes. none Ͼ 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes. these tumors are seen in the mucosa of the cheek and the larynx. Յ 3 cm in greatest dimension N2 Metastasis in a single ipsilateral lymph node. Ͼ 3 cm but Յ 6 cm in greatest dimension. or in multiple ipsilateral lymph nodes. Other morphologic types of squamous cancers in the head and neck include the exophytic. above the supraclavicular fossa N2 Bilateral metastasis in lymph node(s).7 AJCC Stage Grouping for Head and Neck Tumors Nasopharyngeal cancer Stage 0 Tis Stage I T1 Stage IIA T2a Stage IIB T1 T2 T2a T2b T2b Stage III T1 T2a T2b T3 T3 T3 Stage IVA T4 T4 T4 Stage IVB Any T Stage IVC Any T All other head and neck cancers Stage 0 Tis Stage I T1 Stage II T2 Stage III T3 T1 T2 T3 Stage IVA T4 T4 Any T Stage IVB Any T Stage IVC Any T N0 N0 N0 N1 N1 N1 N0 N1 N2 N2 N2 N0 N1 N2 N0 N1 N2 N3 Any N N0 N0 N0 N0 N1 N1 N1 N0 N1 N2 N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 AJCC ϭ American Joint Committee on Cancer. 1997. Lymphoepithelial carcinomas or lymphoepitheliomas are poorly differentiated squamous cell carcinomas with lymphoid stroma. Յ 6 cm in greatest dimension. the ulcerating. Philadelphia: Lippincott-Raven. As a generalization. Chicago. Philadelphia: Lippincott-Raven. none Ͼ 6 cm in greatest dimension N3 Metastasis in a lymph node Ͼ 6 cm in greatest dimension Notes: Histologic examination of a selective neck dissection specimen should include six or more lymph nodes. AJCC ® Cancer Staging Manual (5th Edition). These tumors are seen most commonly in the nasopharynx and tonsil and are notable for their radiosensitivity. The depth of invasion has been correlated directly to the incidence of cervical nodal metastases and survival . Commonly.6 Node Staging of Head and Neck Tumors Nasopharyngeal cancer NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Unilateral metastasis in lymph node(s). and the depth of invasion of the tumor. above the supraclavicular fossa N3 Metastasis in a lymph node(s) N3a Ͼ 6 cm in greatest dimension N3b Extension to the supraclavicular fossa All other sites except the thyroid gland NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node. recent studies indicate this is uncommon and should not prevent consideration of radiotherapy as a treatment option. the presence of lymphatic. vascular. surgical excision has been the preferred form of treatment. and the inﬁltrating types.
in which surgery is known to produce poorer functional results . and immunotherapy.. 1993. AR Shaha. the larynx in patients with advanced head and neck tumors). remain surgery and radiotherapy. features of the tumor and patient and physician factors). Early-stage disease (stage I and stage II) can be treated with either surgery or radiotherapy with equivalent control rates.310 CLINICAL ONCOLOGY N1 < 3 cm N2a 3–6 cm N2b Multiple nodes < 6 cm N3 > 6 cm Single or multiple Bilateral N2c or Contralateral node(s) < 6 cm Figure 12. chemoradiotherapy is used for inoperable tumors and as salvage therapy for recurrent tumors. (Reprinted with permission from JP Shah. J Medina. Curr Probl Surg 30:273–344. disease stage. chemotherapy. histology. Features of the tumor having an impact on treatment include the site. wide local excision is preferred over radiotherapy. individual patients are treated best using a tailored approach. previous treatment.) TREATMENT The management of head and neck cancer requires both a detailed evaluation of the extent of disease and a multidisciplinary approach.g. The main treatment modalities for head and neck cancer. A combination of chemotherapy and radiotherapy is used commonly for patients with advanced nasopharyngeal cancers and for patients with stage III or stage IV laryngeal cancer for organ preservation. When these various parameters are considered. medical condition (including cardiopulmonary status). Decisions regarding appropriate treatment are based on an overall consideration of a variety of factors (e. For patients treated with primary surgery. radiotherapy. Cervical lymph node metastasis. and need for reconstructive surgery. Several randomized and nonrandomized trials have evaluated chemotherapy for treatment of head and neck cancer . and various chemotherapeutic agents have been shown to produce response. However.. have demonstrated an improvement in survival. In addition. chemotherapy in conjunction with radiotherapy has been used successfully to preserve the function of important organs (e. radio- . size. At present. the preference of treating physicians. therefore. one strategy is to reserve primary use of this modality for certain lesions. depth of invasion. and compliance. Last. patient preference. and institutional policy. Therapeutic options include surgery.g. None of these agents. the role of immunotherapy remains investigational. such as those of the larynx.10 TNM staging system for cervical lymph nodes. et al. treatment cost and convenience. For small lesions of the oral cavity.. in any combination. the type of treatment delivered will depend also on the availability of the necessary expertise and multidisciplinary personnel. Patient factors that merit consideration include the impact on quality of life. Since any site can usually receive radiotherapy only once.
Unknown Primary Tumors An unknown primary tumor is deﬁned as the presence of metastatic cancer in the neck while the primary tumor remains undetected despite thorough physical. Advantages of postoperative irradiation include reduction in target tumor volume. iridium. and peripheral areas (including distant lymph nodes) receive the lowest doses.Head and Neck Cancer therapy is used if indicated in the postoperative setting.8 Indications for Postoperative Radiotherapy Features of the primary tumor Advanced T stage (bulky tumor. especially beyond 7. radiation oncologists select the appropriate total and daily irradiation dose. as compared to surgery alone . Complications are reduced further by the use of customized lead-alloy blocks to minimize dose to normal structures..8. Typically. clear deﬁnition of extent of tumor. More advanced lesions (stage III and stage IV) are treated with combined-modality therapy using surgery followed by radiotherapy. but never less than 4. Often. interstitial irradiation applying radioisotopes (e. The primary site receives the higher doses. This technique enables safe delivery of doses adequate to eradicate tumor. with dose delivered to each region corresponding to the amount of cancer present in that region at the time of presentation.600 cGy.500 cGy in 4.. A variety of tools and techniques are available to radiation oncologists in designing a treatment plan. Generally. and oropharynx.000 cGy are required to eradicate large (T3 and T4) tumors. and fewer wound complications in nonirradiated patients than in patients irradiated preoperatively. oral cavity. radium. involvement of bone. or gold) may be used to augment dose locally to desired areas while maximally sparing normal tissues. Subclinical microscopic cancer requires at least 5. Survival in each arm was 68%. depending on the margin status and the pathologic ﬁndings. photon-beam irradiation generally is delivered by megavoltage irradiation. Electron-beam therapy is superﬁcially 311 Table 12. endoscopic. Photon-beam irradiation has the advantage of relative skin sparing. doses in excess of 7. The European Organization for Research and Treatment of Cancer phase III randomized trial of larynx-preserving therapy in advanced hypopharyngeal cancer further validated the use of organ-preserving chemoradiation approaches . Strict attention is paid to patient immobilization by the frequent use of customized immobilization molds to ensure that treatment is delivered accurately and reproducibly each day of therapy. daily doses are 180 cGy (or rads) or 200 cGy. Interstitial implantation or brachytherapy has shown very promising results in patients with tumors of the base of the tongue. interstitial implants are used in an effort to escalate doses safely to the high levels necessary for permanent control of larger lesions. small lesions (T1) require 6. Postoperative radiotherapy is administered with the intent of sterilizing any residual disease. Adjuvant postoperative radiotherapy should be considered for all patients with locally advanced cancers and for patients who have early cancers and ominous pathologic ﬁndings.000–6. but as many as 64% of patients in the chemoradiation arm retained a functional larynx.000 cGy. intermediate lesions (T2) require 6.g. Depending on the disease treated and the clinical situation. the risk of complications increases as dose increases. generally. and radiologic examination by multiple examin- . The role of chemoradiotherapy in preserving laryngeal function without compromising survival was brought into focus by the Department of Veterans Affairs Laryngeal Cancer trial  that compared conventional treatment (surgery with postoperative irradiation) and induction chemotherapy followed by radiotherapy in patients with advanced laryngeal cancer. Postoperative radiotherapy improves local control and survival.g.000 cGy. Features of tumors that mandate postoperative radiotherapy are listed in Table 12. the posterior cervical nodes). For lesions in the nasopharynx.600–7.5 weeks. or skin) High histologic grade Positive surgical resection margins Lymphatic permeation Vascular invasion Perineural spread Features of the cervical lymph nodes More than two pathologically involved nodes Involvement at more than one lymph node level in the neck Lymph node Ͼ 3 cm in diameter (N2 or N3 stage) Presence of extracapsular spread Microscopic or gross residual disease in the neck Involvement of critical levels (IV or V) penetrating and therefore is used as an accessory technique to boost doses to superﬁcial regions of the head and neck (e. nerves. iodine. On the basis of tumor size and individual clinical situations.000 cGy delivered over a ﬁve-week period. However. as the effects of the beam are in deeper structures. postoperative irradiation is recommended to begin within six weeks of the operation. Shrinking-ﬁeld techniques are applied.
or stomach. spinal accessory nerve. Occasionally. lymphoma). and pyriform sinus) is controversial because of the low diagnostic yield. The standard treatment of metastatic squamous cell carcinoma with an unknown primary lesion remains neck dissection followed by radiotherapy. examination under anesthesia. consideration of it is prudent only after thorough evaluation with imaging. and panendoscopy includes evaluation of the nasopharynx. with 50% of these originating in the lungs. One-third of cervical metastases are found to have their primary origin infraclavicularly. with routine sacriﬁce of the internal jugular vein. pancreas. The role of radiotherapy in treating other potential primary mucosal sites also is controversial . stomach. Generally. Although open biopsy of a neck node has not been shown conclusively to alter prognosis . The role of “blind biopsies” of certain high-risk areas (e. one-third originate from the nasopharynx and oropharynx. the nasopharynx should be included routinely in the irradiation portals. directed biopsies of speciﬁc primary sites can be performed. Elevated serum Epstein-Barr virus antibody titers may indicate the presence of nasopharyngeal cancer. pancreas. Neck Treatment of the neck is required in two situations: elective treatment for clinical N0 disease and management of node-positive disease. The prognosis is better in patients whose primary tumor never is identiﬁed. as the location of the cervical adenopathy usually correlates with the location of the occult primary lesion. metastatic adenocarcinoma of the neck originates in structures below the clavicle (e. one-third arise from the tonsil and base of tongue. near the lower portion of jugular vein) is considered to be a systemic disease and is treated best by chemotherapy. and prognosis depends on the pathologic features of the metastatic cancer. Mucosal recurrence rates after treatment range from 11% to 14%. patients with enlarged lymph nodes only at level III or level IV may be spared irradiation of the nasopharynx. Such imaging studies as CT or MRI are extremely helpful and must be an early part of the diagnostic workup in suspected patients. and this incidence is similar to that of second primary tumors for which no prophylactic radiotherapy is recommended. if the plan involves waiting for a ﬁnal histologic report. described by George Crile  in 1906 and popularized by Hayes Martin . nasopharynx. ers. For the past half century. a primary tumor may be located in the salivary gland . and ovary). esophagus. ovary. radical neck dissection. lung. affected patients should be prepared for the possibility of a formal neck dissection on the basis of the report of frozen-section analysis. The rationale in withholding radiotherapy is that the primary tumor will manifest itself in only approximately 4–16% of patients on long-term follow-up. and FNA of the node are found to be inconclusive or are suggestive of alternative pathology (e. The procedure involves excision of all lymph nodes in the neck from level I to level V. metastatic adenocarcinoma to the supraclavicular region presenting as Virchow’s lymph node (supraclavicular or scalene node. and sternocleidomastoid muscle. If open biopsy must be done. and ovary account for the remainder. breast. base of the tongue. The role of neck dissection in the management of metastatic adenocarcinoma is extremely limited and is reserved for palliation of a fungating tumor or pressure symptoms.g. and testes. pharynx. Two-thirds of tumors identiﬁed subsequent to deﬁnitive therapy are found to originate above the clavicles. and dissection of tissue planes must be kept to a minimum to avoid tumor spread. followed in frequency by midjugular and supraclavicular chains. and the use of ﬁberoptic telescopes and nasopharyngoscopes provides access to otherwise difﬁcult areas. This ﬁnding is relevant. depending on the location of the nodal metastases. tonsils. the breast. Examination under anesthesia is routine. Considerable controversy concerns whether the nasopharynx should be included in the portals for postoperative radiotherapy.. The importance of a thorough evaluation of the head and neck cannot be overemphasized.. Generally. Generally. including histologic features (squamous versus adenocarcinoma versus anaplastic). the supraclavicular nodes are involved by metastatic tumors from lung. The exact extent of endoscopy depends on the location of the metastatic tumor. If the metastatic nodal disease involves the upper neck or affected patients present with an elevated serum antibody titer to Epstein-Barr virus.g. These nodes may be involved also in tumors of the breast. metastases to the neck from infraclavicular primaries involve the supraclavicular nodes. and lungs. has been considered standard treatment for the node-positive neck. great care must be taken to place the incision so that it can be excised with the deﬁnitive resection.g.312 CLINICAL ONCOLOGY Alternatively. On the other hand. On the basis of patterns of lymphatic drainage of the head and neck and the incidence of nodal metastases. pancreas. tumor grade. stomach. and the presence of extracapsular spread. the upper jugular lymph nodes are affected most commonly.. In the mid- . Although any lymph node group may be involved. larynx. and a few arise from the hypopharynx. Generally.
Suarez  and Bocca  popularized the modiﬁed neck dissection on the basis of their contention that the morbidity of radical neck dissection (Table 12. Radiotherapy alone (6. saving the internal jugular vein on the side with lesser disease and performing radical neck dissection on the side of bulky disease. blindness. Richard Jesse. has become a routine staging procedure for most tumors of the oral cavity . Allando Ballantyne. Although irradiation and surgery are equally effective in controlling the N0 neck. however. edema of face and neck 1960s. staging the procedures at separate operations may be a good alternative. routine radiotherapy generally is avoided because of the complications related to radiotherapy and its potential long-term sequelae. An important note is that as many as 30% of patients with N1 disease will experience recurrent disease in the neck if treated with surgery alone. airway obstruction. and III. Performing a modiﬁed neck dissection is preferable.9)—especially loss of shoulder function due to sacriﬁce of the spinal accessory nerve—could be minimized with no compromise in local control rates. The supraomohyoid neck dissection.8). This and other classiﬁcation systems for neck dissections are itemized in Table 12. ear lobe. Radical neck dissection is the standard operation for many patients with N2 or N3 disease involving. Over the ensuing years. In an effort to clear the confusion. aspiration Horner’s syndrome Paralyzed ipsilateral diaphragm Weakness or paralysis of limb muscles Chyle leak Pneumothorax (tension) Salivary ﬁstula Bradycardia Cerebrovascular stroke Hypotension. when surgical resection of the primary tumor requires access to the neck and limited or selective neck dissection can be added to the procedure without additional morbidity. II.000 cGy) will result in sterilization of 90% of pathologically involved nodes mea- . the roles of radical neck dissection and routine sacriﬁce of uninvolved structures are becoming unpopular.10 (Robbins et al. thereby subjecting them to potential complications.9 Complications of Radical Neck Dissection Timing and Nature of Complication Intraoperative Injury to nerves Marginal mandibular nerve Hypoglossal and lingual nerve Vagus nerve Sympathetic chain Phrenic nerve Brachial plexus Injury to thoracic or major lymphatic duct Injury to dome of pleura Injury to pharynx or esophagus Other complications Stimulation of carotid bulb Injury to internal carotid artery Air embolism through major venous injury Sequelae 313 Deformity of angle of mouth Difﬁculty in moving the tongue Hoarseness. the American Academy of Otolaryngology-Head and Neck Surgery convened a special task force that published its report in 1991 . In the treatment of node-positive disease. as compared with rates of 30–50% for surgery alone. a procedure that has resulted in improvement of local control rates to more than 70% for N2 and N3 disease. Numerous modiﬁcations were practiced and proposed. In the rare event that bilateral radical neck dissections are indicated. which includes removal of lymph nodes at levels I. the vein. . mortality Early and intermediate postoperative Reactionary or secondary Hematoma hemorrhage Carotid artery exposure and Mortality or rupture cerebrovascular stroke Physiologic consequences Spinal accessory nerve Other nerves Internal jugular vein ligation (bilateral) Shoulder dysfunction Anesthesia of skin ﬂaps. and postoperative radiotherapy should be considered (as indicated).Head and Neck Cancer Table 12. or in close proximity to. nerve. or muscle. Almost all patients with node-positive disease require postoperative radiotherapy (see Table 12. Management of the clinically negative neck continues to generate controversy. causing considerable confusion in nomenclature. ). every effort is made to preserve the accessory nerve and its function. A risk of micrometastases of less than 15–20% is insufﬁcient justiﬁcation for electively irradiating the remaining 80% of patients unnecessarily. Elective treatment is considered on the basis of the perceived risk of micrometastases and should be undertaken if the probability of micrometastasis is more than 15–20%. Medina . In selected patients with N1 tumors. and cheek Cerebral edema. and Spiro et al. Simultaneous bilateral radical neck dissection is a very morbid procedure and is associated with a mortality of approximately 17% (see Table 12. especially those with involvement of nodes away from the spinal accessory nerve. and Robert Byers popularized modiﬁed neck dissections in the United States . An exception may be made.9).
Radiotherapy is the treatment of choice for most patients. bone scan) . Nasopharynx The World Health Organization (WHO) classiﬁes nasopharyngeal tumors into three main classes: WHO 1. Histologic type has a signiﬁcant impact on outcome. WHO 2.000– 6. Generally. Typically.10 Comparison of Neck Dissection Terminology Robbins et al  Radical neck dissection Medina  Comprehensive neck dissection (all ﬁve node levels resected) Radical neck dissection Modiﬁed radical neck dissection Type I (XIn preserved) Type II ( XIn and IJV preserved) Type III (XIn. doses in the range of 5. combined surgery and irradiation should be used to treat patients with N2 and N3 disease. Accurate imaging using CT or MRI (or both) is crucial to determining the extent of disease. MRI seems to be more sensitive than CT in detecting skull base erosion. while at the same time overall disease control decreases with increasing bulk. Doses of irradiation required for tumor eradication increase as a function of disease bulk. suring less than 2 cm. with the exception of primary tumors of the nasopharynx or tonsillar fossa. and all patients with nodal disease may undergo workup for distant disease (chest radiograph. and sternomastoid preserved) Selective neck dissection (fewer than ﬁve node levels resected) Spiro et al. bone erosion. treatment with radiotherapy and chemotherapy results in better local control and survival in patients with undifferentiated tumors (WHO 3) as compared to those with keratinizing tumors . Tumors of the nasopharynx are peculiar in that approximately 75% of affected patients will present with cervical nodal metastases. local extension to parapharyngeal spaces and orbit.300 cGy is required in the postoperative setting. with treatment portals encompassing structures from the base of the skull . To minimize the risk of disease progression and treatment morbidity. IJV ϭ internal jugular vein. the incidence of asymptomatic distant metastases is 40%. no more than four to six weeks should elapse between therapies. keratinizing squamous cell carcinoma. and involvement of the retropharyngeal nodes . and the presence of cervical metastases. and even massive nodal disease responds well. lymphoepithelioma or poorly differentiated tumor . Nodes larger than 3 cm rarely disappear during the course of irradiation. Wide-ﬁeld irradiation is mandated. Approximately 80% of nodes larger than 3 cm are controlled by doses of 7. In patients presenting with bulky nodal disease. especially the retropharyngeal nodes that are the ﬁrst-station nodes. IJV. and WHO 3.314 CLINICAL ONCOLOGY Table 12. wherein a complete response to irradiation often occurs despite advanced nodal disease.  Radical neck dissection (four or ﬁve node levels resected) Conventional radical neck dissection Modiﬁed radical neck dissection Extended radical neck dissection Modiﬁed and extended radical neck dissection Selective neck dissection (three node levels resected) Supraomohyoid neck dissection Jugular dissection Any other three levels resected Modiﬁed radical neck dissection (preservation of one or more nonlymphatic structures) Selective neck dissection (preservation of one or more lymph node groups) Supraomohyoid neck dissection Posterolateral neck dissection Anterior compartment neck dissection Lateral neck dissection Extended radical neck dissection (resection of additional lymph node groups or nonlymphatic structures) Limited neck dissection (no more than two node levels resected) Paratracheal node dissection Mediastinal node dissection Any other 1 or 2 levels resected XIn ϭ spinal accessory nerve. nonkeratinizing carcinoma.000 cGy are given to involved nodes in a preoperative setting. whereas approximately 6. soft-tissue invasion outside the nasopharynx. liver ultrasonography.000 cGy.
but the overall ﬁve-year survival rate is only 50% . reserving neck treatment for more advanced lesions (T3-T4 node-positive). The ﬁve-year survival rates for patients with stage I and stage II disease are 90% and 70%. including endocrine dysfunction of the pituitary gland. The treatment decisions depend on T stage. Early lesions of the tongue can be excised with minimal functional consequences. Reconstruction using microvascular free-tissue transfer (e.g. Brachytherapy may be used to boost treatment in selected cases . The role of surgery in treating the local site is very limited. depending on the tumor’s relation to the mandible. However.Head and Neck Cancer to clavicles to cover the primary site and all cervical lymph nodes. An ipsilateral supraomohyoid neck dissection is undertaken for tumors that are believed to inﬁltrate beyond 2–3 mm into the substance of the tongue . and incidence of gross or occult nodal metastasis. epirubicin. 315 Oral Cavity The most common sites of tumors in the oral cavity are the tongue and the ﬂoor of the mouth. for patients with N1 to N3 disease. The indications for postoperative radiotherapy are listed in Table 12. Likewise. lesions involving the commissure or larger lesions should be considered for treatment with radiotherapy to minimize cosmetic or functional morbidity. Excision of small lesions involving no more than 33% of the lower lip or 25% of the upper lip can be performed with minimal cosmetic or functional sequelae. external-beam irradiation. Primary radiotherapy delivering 70–72 Gy in six weeks controls approximately 75% of early tumors . a large. radial forearm ﬂap) produces good functional results. size. radiologic imaging. and the defect can be closed primarily or by skin graft or may be left open to heal by secondary intention. Small lesions may be ex- . Surgery and radiotherapy give equal cure rates for early buccal lesions. More advanced lesions are treated with a combination of surgery and postoperative radiotherapy. Surgical excision. and bleomycin followed by irradiation has shown a signiﬁcant survival advantage over irradiation alone (47. For patients with N0 disease. Typical doses in the range of 66–72 Gy are delivered to the primary site. Small lesions of the ﬂoor of the mouth also can be excised transorally. Persistent nodal disease after radiotherapy may be treated with neck dissection. but irradiation failures present at a higher stage and are more likely to require extensive surgery and reconstruction. In certain selected cases. relation to the mandible (proximity or involvement). the ﬁve-year survival rate drops to 65%. such as the Abbe-Estlander or Karapandzic ﬂaps. Early-stage lesions can be treated equally effectively using surgery or radiotherapy. and involved surgeons may have a role in providing access for placement of brachytherapy catheters.. Small defects can be closed primarily or can be left to heal by secondary intention.1% versus 30%) . Patients with larger lesions require more complex reconstruction. A posterior lesion may require the mandibular swing approach for adequate exposure. Functional consequences of surgery include microstomia and oral incompetence. Laboratory testing must include monitoring of treatment-related side effects. Posttreatment follow-up includes careful examination. or temporary interstitial implant alone yields local control in more than 90% of cases. using a shrinking-ﬁeld technique to maximize dose to sites of gross disease. Excision of a primary tumor may require a cheek ﬂap or mandibular resection. Whenever a lesion in the anterior ﬂoor of the mouth near the opening of the submandibular salivary glands is excised. treatment should be directed only at the primary site. the duct may be transposed into the adjacent normal mucosa. the ﬁve-year survival rate is 85%. location (anterior or posterior). the complication rates after radiotherapy are higher. The treatment of advanced disease involves addition of cisplatin-based chemotherapy to radiotherapy. Selected patients with small recurrences may be salvaged by surgery . Three-dimensional conformal therapy seems to target the tumor in a very precise fashion. For patients with early-stage (T1-T2 N0) disease. The ﬁve-year survival rates are 85% for patients with T1 and T2 lesions and 75% for patients with T3 and T4 disease. due consideration must be given to excision of the submandibular gland. owing to the risk of obstructive sialadenitis. A randomized trial of neoadjuvant chemotherapy using cisplatin. Larger lesions are treated most effectively by combining surgery with postoperative radiotherapy. Although surgery and irradiation provide equivalent results. Small lip lesions can be excised in the fashion of a V with primary closure or local ﬂap reconstruction. multicenter randomized trial has demonstrated superior control and survival in patients treated with concomitant cisplatin and irradiation as compared to irradiation alone .8. both of which are more common after extensive resection. respectively. More extensive lesions may require marginal or segmental mandibulectomy (discussed later). and investigation of symptoms. The survival results drop to approximately 55– 65% for advanced tumors treated with combinedmodality treatment .
Oropharynx The oropharynx sites involved most commonly are the tonsils and the base of the tongue. Five-year T-stage-speciﬁc survival rates are 45% for patients with T1 and T2 disease and 10% for patients with T3 and T4 disease. Usually. and 15% for T1 through T4. Primary radiotherapy is the preferred deﬁnitive treatment for most early tumors of the base of the tongue. early-stage disease can be treated by either radiotherapy or surgery. Treatment decisions are dictated by anatomic and tumor factors and by morbidity associated with the various therapeutic modalities. 55%. and resection of most tonsillar and base-oftongue tumors requires a lower lip-splitting incision with a mandibulotomy. with decreased treatment-related morbidity and improved local control [33–36]. but more advanced lesions. Gaining access to the larger lesions of the oropharynx through the open mouth is difﬁcult. Composite resection may result in a fullthickness soft-tissue defect with bone loss that may need microvascular free-tissue transfer. The overall ﬁve-year survival rate for such patients is reported at 26%. Other sites are the soft palate and the pharyngeal wall. Radiotherapy is chosen more often than surgery for most early lesions because the cure rates are high and the functional outcome is better. including the retropharyngeal lymph nodes. 37–39. the standard surgical approach to base-of-tongue lesions includes resection of the base of the tongue by the mandibulotomy approach and ipsilat- cised through the open mouth. yielding an ultimate local control of 90%.316 CLINICAL ONCOLOGY The most common approach for locally advanced lesions is surgery followed by radiotherapy. which may be managed by partial or composite resection. External irradiation of the neck is performed in lieu of a neck dissection in patients who present with clinically negative (N0) necks. 40. or the mandible require more extensive surgery. Chemoradiation followed by implant and neck dissection may be considered in the treatment of advanced lesions that otherwise would require total laryngectomy at the time of presentation if treated surgically. surgery includes neck dissection. and salvage surgery is successful in approximately two-thirds of patients. Five-year Nstage-speciﬁc survival rates are 45% for patients with N0 disease and 20% for patients with N1 to N3 disease [27. Fiveyear T-stage-speciﬁc survival rates have been reported to be 89%. Irradiation may be delivered as external-beam treatment alone or in combination with an implant. and the defect can be left open to heal by secondary intention or may be closed by skin graft. The advantage of the latter approach is relative sparing of normal surrounding tissues. whereas more advanced lesions are treated by combinations of these methods. which may be improved by twice a day fractions. the full thickness and skin of the cheek. although deﬁnitive radiotherapy with the addition of a neck dissection for node-positive patients is a reasonable alternative. Radiotherapy of advanced lesions (T3-T4) achieves local control rates in the range of 25–70%. Surgery is the preferred modality in view of the proximity to bone. . are resected best surgically and followed up with postoperative irradiation. 45. Inﬁltrative or endophytic T3 or T4 lesions call for either surgery combined with postoperative radiotherapy or an organ-preserving approach using radiotherapy and chemotherapy. 46]. Larger lesions and those that involve the oral commissure. closure may be attained primarily or by a pedicle or free ﬂap. and the overall survival rate is approximately 60%. which optimizes functional outcome . One treatment approach calls for a combination of external-beam irradiation (50–54 Gy) plus an interstitial 192Ir implant (20–30 Gy) to treat a primary site and external-beam irradiation combined with a neck dissection to treat cervical lymph nodes when indicated . Early tonsillar tumors can be treated with radiotherapy. Approximately 50–75% of patients will be alive and free of disease ﬁve years after treatment . Lesions of the alveolar ridge have a greater propensity to metastasize to cervical nodes. Lymphatic metastasis is an early and common feature of tonsillar tumors. respectively. Irradiation treatment portals encompass both the primary site and the ipsilateral neck. 29. Depending on the size and location of a soft-tissue defect. Most patients need a neck dissection because of the high incidence of cervical metastases. Radiotherapy for T1 and T2 lesions results in local control rates of 70–90%. In general. Care is taken to minimize dose to the contralateral parotid gland to reduce the risk of xerostomia. If surgery is used. Patients who present with bulky nodal disease and a small primary tumor may be managed with bimodality therapy: neck dissection followed promptly by radiotherapy to control the primary site . Irradiation portals include sites of primary involvement and sites of probable extension and bilateral regional and retropharyngeal lymph node groups. 49%. A number of investigators have demonstrated that the combination of externalbeam irradiation and an implant boost is an effective treatment for patients with base-of-tongue cancer. especially those with metastatic nodes.
Inc. J Surg Oncol 49:116–119. Marginal mandibulectomy can be performed via a horizontal. either because it may be involved by the disease or because it may limit access to the primary tumor. No deﬁnitive investigation can evaluate the status of the mandible with absolute accuracy. vertical. 12. Imaging modalities available include dental x-ray ﬁlms. MRI. both of which adversely impair ability to work. especially those who present with lesions that are in close proximity or adherent to the medial aspect of the mandible. The functional consequences of resection of these tumors includes signiﬁcant difﬁculty with speech and swallowing. it has been shown that tumors of the oral cavity spread to the mandible by direct extension along the alveolar ridge through pores on the alveolar border or through the dental socket. horizontal. a total glossectomy or a supraglottic (or even total) laryngectomy may be necessary. all potential candidates for bone resection must undergo radiologic imaging for planning and preparation of templates for mandibular reconstruction. and CT. the radial forearm-free microvascular ﬂap yields best functional results. Often. Preoperative evaluation of the mandible is vital to the proper management of patients with oral cavity cancer. Understanding of tumor spread to the mandible from oral cavity cancer has evolved considerably.11) . and eating in public. Selected small defects may be left open to heal by secondary intention. and a mandibulotomy is used if greater access is required for lesions in the posterior oral cavity or oropharynx. 1992.11 Various types of marginal mandibulectomies: vertical. Small tumors of the base of the tongue may be resected by the transhyoid pharyngotomy approach. Mandible The mandible must be considered in the management of oral and oropharyngeal cancers. This improved understanding of the anatomy of spread has led to a trend away from routine segmental mandibulectomy. toward conservation of the uninvolved mandible. dentascans. a subsidiary of John Wiley & Sons. communication with others. (Reprinted with permission of Wiley-Liss. Although the reliability of imaging in detecting bony involvement is low. as are tumors of the retromolar region. Mandibular swing or mandibulotomy is indicated for surgical access to tumors of the posterior oral cavity or .) eral neck dissection with reconstruction. panoramic x-ray ﬁlms of the mandible. Inc. the edentulous mandible is at high risk for direct invasion. especially if a tumor invades the diaphragm of the ﬂoor of the mouth. depending on the site and extent of primary disease.” mainly because demonstrating minimal bony invasion radiologically is difﬁcult . Clinical evaluation remains the best “test.Head and Neck Cancer 317 Vertical Horizontal Oblique Figure 12. tumors were believed to spread to cervical lymph nodes along lymphatic channels that pierce the mandibular periosteum and bone. and all imaging modalities have a high incidence of false-positive results. and bone scans. which was used for access. nodal metastases. The oblique cut has the advantage also of providing better tumor clearance. or oblique cut (Fig. A panoramic view of the mandible may be useful to evaluate the extent of resection necessary in the event of gross destruction of bone.. Clearly. and advanced local disease. Dental ﬁllings lead to considerable artifacts on CT scan. In the past. The defect after marginal mandibulectomy can be resurfaced easily by advancement of adjacent mucosa or by a split-thickness skin graft. Use of the oblique method allows retention of a strong mandibular remnant.. For larger defects. from AR Shaha. Marginal mandibulectomy for carcinoma of the ﬂoor of the mouth. The majority of patients managed surgically require postoperative irradiation because of close resection margins. However. and oblique cuts. Minimal periosteal or bone involvement can be treated with marginal mandibulectomy.
otherwise. These include preirradiation dental evaluation and extraction of unhealthy teeth. The cosmetic and functional results are excellent. owing to sparse lymphatic supply. genial muscles do not have to be divided. including those of the deep lobe of the parotid.318 CLINICAL ONCOLOGY beneﬁt from aggressive surgical excision and immediate microvascular reconstruction . but the choice of donor site depends largely on the bone stock required. sarcoma). because the risk of lymph node involvement is very small. frequently required for recurrence. now is routine practice. and regular followup through the course of irradiation. hyperbaric oxygen. the swing is performed by incising the mucosa of the ﬂoor of the mouth along the medial aspect of the mandible posteriorly toward the region of the tumor. This approach also provides good exposure for resection of parapharyngeal tumors. local control rates of 60–80%. long-term antibiotics. Selected patients with more extensive necrosis may Larynx In the United States. cartilage invasion contraindicates irradiation as a primary modality. reconstruction with A-O plates may be performed. and the mandibular segments can be ﬁxed adequately using miniplates or stainless steel wires. Microvascular ﬂaps have been shown to tolerate postoperative radiotherapy well and. the soft-tissue defect. use of intensive de oral irrigations and. occasionally. though PET scanning seems to be a useful new tool . the inferior alveolar nerve and vessels are spared. especially after segmental resection of the arch. After the osteotomy is complete. owing to the readily apparent symptom of hoarseness. Segmental resection of the uninvolved mandible purely to gain access generally is not advocated. owing to the availability of microvascular free ﬂaps. verrucous. lateral mandibulotomy is not indicated routinely. Surgery may involve endoscopic excision with a CO2 laser or. Patients with cord ﬁxation (T3) or thyroid or cricoid cartilage invasion (T4) can be offered either total laryngectomy with postoperative irradiation. can be achieved using partial laryngectomy [54.. repeat stripping. The mandibular osteotomy may be situated in either a paramedian or a midline location. Primary mandibular reconstruction. limited osteoradionecrosis may be treated conservatively with ´ bridement. and the choice of the individual microvascular surgeon . Surgery is slightly better at controlling early (T1 and T2) lesions than is irradiation alone. the osteotomy lies outside the portal of irradiation. Irradiation ﬁelds for T1 and T2 glottic tumors encompass only the primary site. iliac crest. so that salvage laryngectomy may be performed in a timely manner if necessary. results in a thickened cord and hoarse voice. Patients who accept the nonsurgical approach must be able to undergo frequent followup examinations. and prophylactic measures must be instituted before commencing treatment.e. Generally. Early. or attempted organ preservation with chemoradiation. as demonstrated by Spiro et al. equivalent to those for total laryngectomy. as indicated. Either supraglottic laryngectomy or external-beam . after completion of therapy. Patients with advanced oral or oropharyngeal tumors that involve the mandible will require mandibular resection and reconstruction. cosmetic and functional results can be improved with osseointegrated dental implants. surgery should be offered when the histologic type is relatively resistant to irradiation (i. However. avoiding the need for dental extraction. and therefore have a relatively better prognosis. Tumors of the glottis present early. Treating osteonecrosis of the mandible after radiotherapy is difﬁcult. However. adenocarcinoma. oropharynx. whereas tumors in the other two sites have a tendency to remain silent and present late. and scapula. laser treatment. Owing to decreased local control with radiotherapy. but success rates are limited. ﬂuoride treatment. or external-beam irradiation. Radiotherapy should be considered in patients who experience rapid or multiple recurrences after cord stripping or laser treatment. glottis (69%). Vocal cord cancers metastasize to cervical nodes less frequently. . laryngoﬁssure with cordectomy or vertical partial laryngectomy. 55]. The clinical differentiation between residual or recurrent tumor and osteoradionecrosis may be difﬁcult. and subglottis (1%) . and the extrusion rate is high. tumors of the larynx involve the supraglottis (30%). Laryngeal conservation is possible in approximately 70–90% of radiotherapy failures. A paramedian mandibulotomy is superior to a midline or lateral mandibulotomy for the following reasons: The paramedian osteotomy can be situated in the natural space between the incisor and canine teeth. T1 and T2 tumors are treated best with irradiation because cure rates are excellent (80–90%) and resultant voice quality is better than that with hemilaryngectomy or partial laryngectomy. Under difﬁcult circumstances. but the control rates are equalized by surgical salvage of irradiation failures. Commonly used ﬂaps include the ﬁbula. Carcinoma in situ may be treated equally well with cord stripping.
total laryngectomy is recommended for unfavorable T3 cancers. All patients routinely undergo neck dissection in conjunction with laryngopharyngectomy in view of the high incidence of nodal metastasis. and IV usually is included for patients with a clinically negative neck. poor patient compliance. Other issues that argue in favor of primary irradiation treatment for affected patients include major medical contraindications. the FDG-PET scan seems to be superior to any imaging modality currently available for differ- 319 entiating recurrent tumor from postirradiation softtissue changes . including the epiglottis and the aryepiglottic folds down to the false vocal cords with the overlying thyroid cartilage and the intervening preepiglottic space. which is designed to remove the entire supraglottic unit. such as the Veterans Administration trial . however. a jugular node dissection for lymph nodes at levels II. and an ipsilateral thyroid lobectomy is performed for tumors that involve the subglottis or the pyriform sinus apex. If total laryngectomy is undertaken. surgery involves total laryngopharyngectomy. Owing to the high incidence of nodal metastasis and the associated poor outcome . Partial circumference defects can be repaired using a myocutaneous or microvascular free-ﬂap patch pharyngoplasty. is relatively well preserved. depending on a variety of factors that include . full circumferential defects are reconstructed with a free jejunal graft. Nasal Cavity and Paranasal Sinuses Surgery for tumors of the nasal cavity and paranasal sinuses ranges from lateral rhinotomy to craniofacial resection. Survival rates of approximately 50–60% have been reported for stage III and stage IV laryngeal tumors [59. and selected T3 squamous cell carcinomas of the supraglottic larynx. but selected patients may be treated with partial pharyngectomy or partial laryngopharyngectomy. Consequently. III. and few patients need long-term nutritional support. The operation is oncologically sound. Four months after treatment. such as exophytic tumor and still-mobile vocal cords or limited cartilage or soft-tissue extension or base-of-tongue invasion. mainly because it results inevitably in some degree of aspiration that may cause postoperative pulmonary problems. but the results are not equivalent to those for laryngeal cancer . now has provided another option. Most often. advanced laryngeal cancer has been treated with total laryngectomy combined with postoperative radiotherapy. Total laryngopharyngoesophagectomy may be required for lesions that extend into the cervical esophagus. if supraglottic laryngectomy is undertaken. III. Only selected patients are suited for this operation. If primary irradiation is the treatment of choice. and only approximately 25% survive ﬁve years after treatment. T2. The combined use of chemotherapy and irradiation in larynx-preserving protocols. Hypopharynx Most patients with hypopharyngeal cancer present in advanced stages. Generally. and the defect is reconstructed using gastric pull-up and pharyngogastrostomy. as poor swallowing does not ensue. especially in the presence of advanced neck metastases. the portals should include the cervical lymph nodes. Patients with hypopharyngeal cancer also have a more than 20% incidence of distant metastases. The risk of local failure after radiotherapy rises to 40–50% in T2 and T3 lesions in the presence of reduced cord mobility. and more than 50% of patients will have palpable cervical lymph nodes at presentation. Traditionally. the majority of patients require combined-modality treatment. 57]. selective neck dissection of levels II. A common dilemma in the follow-up evaluation of patients treated with primary irradiation is the differential diagnosis between radionecrosis and residual or recurrent tumor. and control rates of more than 90% have been reported [56. Patients with more advanced disease can be treated with external-beam irradiation only in the presence of favorable factors. Surgery for early supraglottic cancer involves supraglottic (horizontal) partial laryngectomy. a number of trials are evaluating the role of chemoradiotherapy in organ preservation for such advanced lesions.Head and Neck Cancer radiotherapy may be used with equal efﬁcacy to treat patients with T1. Reconstruction of the pharyngeal defect after total laryngopharyngectomy depends on the extent of mucosal loss. Alternatively. Paratracheal groove nodes are dissected for subglottic tumors. Ideally. The overall prognosis for such patients is dismal. inadequate pulmonary reserve. and advanced age. and IV is used to stage the neck disease and to select patients for postoperative irradiation. Currently. treatment of the neck should be considered in all patients with supraglottic cancer. which include endophytic or bulky tumors that usually are bilateral and often present with vocal cord ﬁxation or airway compromise (or both). The quality of voice. 60]. Primary radiotherapy and chemoradiation have been used in an attempt to conserve the larynx.
The defect after maxillectomy may be resurfaced with a split-thickness skin graft bolstered in place by the temporary prosthesis. A study of treatment of these tu- Recurrent Head and Neck Cancer The treatment of recurrent head and neck cancer depends on the type of previous treatment and the initial extent of the disease. however. Combined treatment with chemotherapy and radiotherapy may be possible in patients who have not received irradiation previously. such as hyperfractionated radiotherapy and chemoradiosensitizers. rectus abdominis ﬂaps are used. Complex and extensive resections may necessitate more complicated reconstruction. Generally. Such surgeons should evaluate the inoperability of the tumor and should obtain a second opinion. Large defects may be reconstructed with microvascular free ﬂaps. Resection of a recurrent tumor should encompass the entire initial extent of a primary tumor rather than encompassing the localized recurrent disease or tumor nidus. In addition. the extent and type of the lesion. a ﬁnal prosthesis is fashioned. Although the overall ﬁve-year survival rate has been reported to range from 35% to 40% . on the other hand. commonly. and tumor adherence to the vertebral bodies. including avoidance of airway problems. which is inserted into the defect at the end of the operation. but the role of chemotherapy requires further study. and care of fungating tumor. Postoperative radiotherapy is used for the usual indications. but no improvement in survival has been demonstrated. Tumors that recur in such locations as the anterior ﬂoor of the mouth can be treated satisfactorily with surgical resection and appropriate reconstruction. For many patients. may require total maxillectomy with resection and reconstruction of the orbital ﬂoor. but treatment was complicated by unilateral blindness in one-third of such patients . an extremely important factor is attending surgeons’ ability to distinguish operable from inoperable lesions.320 CLINICAL ONCOLOGY mors by intraarterial high-dose platinum and radiotherapy (the RADPLAT regimen) is ongoing. Treating infrastructure maxillary lesions is easier. Concurrent cisplatin infusion chemotherapy and hyperfractionated radiotherapy have been shown to result in a complete response rate of 92% and a threeyear survival rate of 58% in a small number of patients with stage IV disease . and the spinal cord. maintenance of nutrition. The best options available under these circumstances may be investigational protocols or new approaches. Small lesions localized to the lateral nasal wall can be excised adequately by a medial maxillectomy through a lateral rhinotomy. orbital exenteration may be necessary if a tumor extends to involve the soft tissue of the orbit. Inoperable Cancer In the evaluation of advanced cancer. invasion of the prevertebral fascia. . Tumors in such other locations as the skull base are not amenable to surgical salvage. equally important is the realization that surgical resection is unlikely to improve survival and at the same time places affected patients at considerable risk of morbidity and even mortality from the radical surgical procedure.11 summarizes the results of randomized trials of induction or adjuvant chemotherapy in patients with advanced head and neck tumors. Ultimately. and the patient can easily care for the skin-graft-lined cavity. Affected patients may require modiﬁcation of the prosthesis as the defect heals and changes shape. Accurate and detailed documentation of the initial extent of disease is vital in all patients undergoing nonsurgical primary treatment. the aim of treatment becomes satisfactory palliation. Advanced. if necessary. when the defect has stabilized. Table 12. Radiotherapy alone (to nodes and primary tumor) has been reported to control disease in 52% of patients at ﬁve years. Treatment of suprastructure lesions. but its delivery is complicated by the proximity of the eye. Though the consideration of surgical resection is tempting in patients who respond to treatment. Adequate rehabilitation of patients undergoing any form of maxillary resection depends on the active involvement of a maxillary prosthodontist. more aggressive resection using the craniofacial approach has improved results . Other contraindications to surgical resection include involvement of the common or internal carotid artery. Preoperative dental impressions are taken to fabricate a temporary prosthesis. Complete response rates vary from 37% to 86%. such tumors can be resected by a partial maxillectomy that removes part of the hard palate along with the medial and lateral walls of the maxillary sinus. Tumors that extend up to the skull base may require a combined craniofacial approach performed by a head and neck surgeon in conjunction with a neurosurgeon. the brain. Cervical lymph node metastasis occurs in approximately 15% of patients and predicts a dismal outcome. and functional and cosmetic results are satisfactory with good local control. but innovations by a prosthodontist often can produce acceptable functional and cosmetic results.
two or three non-cross-resistant agents are used in combination. docetaxel. Chemoradiotherapy for Head and Neck Cancer. 5-FU 70% (19%) S/RT No signiﬁcant difference in survival No signiﬁcant difference in survival 86% (31%) RT versus S/RT Laramore 448 Cisplatin. VA ϭ Veterans Administration. response rates range from 10% to 30% in patients with recurrent or metastatic disease.11 Randomized Trials of Induction or Adjuvant Chemotherapy (or Both) Study Jacobs No. In vitro evidence demonstrates synergy between the two agents : Cisplatin increases intracellular folic acid that in turn promotes the covalent binding of 5- ﬂuorodeoxyuridylate.. no. vol 7. neoadjuvant or induction chemotherapy). S/RT ϭ local therapy with surgery or radiotherapy (or both).] Philadelphia: Lippincott. with complete response rates of 40–60% . Response rates with 5-FU are reported to be signiﬁcantly better when it is administered over a ﬁve-day period as a continuous infusion as compared to a daily bolus injection over the same period. and gemcitabine) are currently being evaluated.g. Chemotherapy and Organ Preservation The role of chemotherapy in the treatment of head and neck cancer has been investigated extensively over the last several decades. RT ϭ radiotherapy. Source: Reprinted with permission from EE Vokes. cisplatin and 5ﬂuorouracil (5-FU) are the most active agents. decreased distant metastases Induction CT. and that this form of therapy . 66–70]. When this combination is used as primary treatment before surgery or irradiation (i. 21.11). [PPO Updates.. CR ϭ complete response. These trials showed that response rates up to 90% can be achieved in previously untreated patients . 5-FU ϭ 5-ﬂuorouracil. decreased distant metastases with adjuvant CT Induction CT. survival beneﬁt for N2 disease by subset analysis. vincristine Cisplatin. NA ϭ not applicable. but newer agents (e. paclitaxel.e. but some conclusions can be drawn from the results of selected trials (see Table 12. an active 5-FU metabolite to its target enzyme. RR Weichselbaum. larynx preservation CT adjuvant to surgery. thymidylate synthase. that the rate of distant metastases can be reduced .Head and Neck Cancer Table 12. With most single agents. 5-FU NA S/RT No signiﬁcant difference in survival CT ϭ chemotherapy. Currently. Generally. bleomycin. vinorelbine. decreased distant metastases. response rates as high as 90% have been reported. of Patients 443 Drugs Cisplatin. decreased incidence of distant metastases Shuller 158 VA larynx study 332 Cisplatin. 6. cisplatin and 5-FU being used the most widely [18. 1993. methotrexate. Neoadjuvant chemotherapy has been found to show no overall survival beneﬁt in randomized trials. bleomycin CT Response Rate (CR) 37% (3%) Local Therapy S/RT Outcome No signiﬁcant difference in survival 321 Comments Induction and adjuvant CT. but these agents no longer are used as monotherapy.
split-course treatment.g. Chemotherapy also has been used concurrently with radiotherapy on the basis of the following rationale: it acts locally and systemically outside the radiotherapy ﬁeld. Early intervention may reduce the risk of malignant progression in patients who have documented premalignant lesions or of second primary tumors in those who have been treated for malignancy. In contrast. The use of vitamin A analogs and cis-retinoic acid has been associated with a beneﬁcial effect but remains investigational. and paclitaxel) act as radiosensitizers. The facial nerve divides the gland into superﬁcial lobes (80% of the substance) and deep lobes (20% of the substance). Combination chemoradiotherapy also has been demonstrated to prolong survival in patients with unresectable primary disease and in those with N2 disease. The parotid gland is the largest salivary gland and is also the most common site of salivary neoplasms. chemotherapy and irradiation have different cellular targets. the role of neoadjuvant chemotherapy remains restricted to the clinical trial setting. 69]. Table 12. This distribution accounts for the dictum that a lesion of the hard palate should be considered a minor salivary gland tumor unless proved otherwise. Then the nerve enters the substance of the gland and divides into two main divisions: the upper zygomaticotemporal division and the lower cervicomandibular division. PREVENTION Head and neck cancer is a disease of lifestyle. With a few exceptions. Major salivary glands include the parotid. 70]. JK Ihde. 1990. and the treatment produces substantial side effects . and cervical. buccal. hydroxyurea. 5FU. A tumor of the sublingual glands can be mistaken easily for a tumor of the ﬂoor of the mouth. Approxi- Parotid gland Submandibular gland Minor salivary glands Source: Reprinted with permission from JP Shah. deep lobe tumors are rare. and prevention includes limiting exposure to such main etiologic factors as tobacco and alcohol (see Chapter 4). and preservation of the facial nerve and its branches. Some have even reported prolonged survival [45. and the mandibular branch (ramus mandibularis). . are functionally the most important of the ﬁve branches. and the bony auditory canal.12). Curr Probl Surg 27:775–883. Injury to these branches during surgery can cause considerable cosmetic and functional disability.322 CLINICAL ONCOLOGY mately 500–700 minor salivary glands are distributed throughout the mucosa of the upper aerodigestive tract. and certain chemotherapeutic agents (e. Malignant tumors of the salivary glands are rare. carboplatin. The submandibular gland lies in the submandibular triangle on the surface of the hyoglossus muscle above may allow for organ preservation in selected patients . but approximately half are located on the hard palate . zygomaticoorbital. mandibular. which gives simultaneous chemotherapy and irradiation with scheduled breaks to allow normal tissues to recover. however. Retinoids have been shown to reverse leukoplakic changes in 55–100% of the patients. The main trunk of the nerve can be located at the conﬂuence of three important anatomic structures: the posterior belly of the digastric muscle. dissection. supplying the eyelids. and half of submandibular gland tumors are malignant. which is one to three doses of single-agent chemotherapy added to an uninterrupted course of irradiation. it divides into its ﬁve main branches: temporal. submandibular. wherein one modality immediately follows the other. Several randomized trials have shown a statistically signiﬁcant beneﬁt in locoregional control with concurrent chemoradiotherapy [68. but the effects are shortlived.. cisplatin. By the time the nerve exits the gland at its anterior and superior borders. and chemotherapy eliminates tumor cells that were damaged sublethally by radiotherapy. supplying the lip.12 Site-Wise Distribution of Salivary Tumors Site Percentage of all Neoplasms 65 8 27 Percentage Malignant 25 50 81 SALIVARY TUMORS The salivary glands can be divided into major and minor types. it acts against radioresistant hypoxic tumor cells. Most parotid tumors involve the superﬁcial lobe. and sublingual salivary glands. the tip of the mastoid process. the majority (81%) of minor salivary gland neoplasms are malignant. Successful surgery of the parotid gland depends on identiﬁcation. Salivary gland tumors. The facial nerve exits the skull through the stylomastoid foramen and passes lateral to the styloid process. The orbital branch. Concurrent chemoradiotherapy can be delivered in one of three ways: the classic course. but the incidence of malignancy depends on the anatomic site involved (Table 12. The majority (75%) of parotid neoplasms are benign. and alternating chemotherapy and radiotherapy.
none Ͼ 6 cm in greatest dimension N2a Metastasis in a single ipsilateral lymph node Ͼ 3 cm but Յ 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes. It does. but a negative ﬁnding cannot rule out cancer. seventh nerve. involved surgeons can prepare affected patients better for appropriate management of the facial nerve.13 and 12. oncocy- toma. 3 cm or less in greatest dimension N2 Metastasis in a single ipsilateral lymph node. Ͼ 3 cm but Յ 6 cm in greatest dimension. Chicago. where it opens just lateral to the frenulum of the tongue. chondroid. For example. Warthin’s tumor. Source: Used with the permission of the American Joint Committee on Cancer (AJCC ®). Benign Parotid Tumors Common benign lesions seen in the parotid gland include benign mixed tumor. AJCC ® Cancer Staging Manual (5th Edition). Approximately 80% of benign parotid lesions are benign mixed tumors. and benign lymphoepithelial lesions. FNA is sometimes unable to distinguish among the various types of salivary gland neoplasms. and in detecting previously unnoticed cervical lymphadenopathy. none Ͼ 6 cm in greatest dimension. but an occasional patient may present with rapid growth in a . and it may reveal valuable information if it is used with the understanding that negative results generally do not constitute a ﬁnal diagnosis. and ramus mandibularis. a benign mixed tumor may occasionally be interpreted as an adenoid cystic carcinoma. 323 Table 12. Primary tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor T1 Tumor Յ 2 cm in greatest dimension without extraparenchymal extension T2 Tumor Ͼ 2 cm but Յ 4 cm in greatest dimension without extraparenchymal extension T3 Tumor having extraparenchymal extension without seventh nerve involvement and/ or Ͼ 4 cm but Յ 6 cm in greatest dimension T4 Tumor invades base of skull. as benign masses almost never cause facial palsy. FNA is a simple technique. and/or Ͼ 6 cm in greatest dimension Regional lymph nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node. Tables 12.13 TNM Staging for Cancers of the Major Salivary Glands Classiﬁcation Deﬁnition Diagnostic Workup Most salivary gland tumors are evaluated adequately by physical examination. 1997. or in multiple ipsilateral lymph nodes. hypoglossal. ﬁxed malignancy. ﬁbroid. especially deep-lobe parotid tumors and minor salivary gland tumors in such locations as the nasal cavity and paranasal sinuses. none Ͼ 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes. or in bilateral or contralateral lymph nodes. and epithelial components that make up the tumor. such tumors grow slowly. FNA cytology is helpful in conﬁrming the diagnosis of malignancy. Radiologic imaging with CT scanning or MRI is helpful in evaluating the extent of disease. Palpation of the parotid gland may reveal an obviously hard. Generally. Although minor salivary gland tumor staging is similar to that used for squamous cell carcinoma arising in the same location.Head and Neck Cancer the digastric. The presence of facial nerve paralysis is an extremely reliable indicator of malignancy. They are classiﬁed histologically as pleomorphic adenoma owing to the diversity of myxoid. however.14 shows the American Joint Committee on Cancer staging for cancer of the major salivary glands. Philadelphia: Lippincott-Raven. even when they become huge. If the FNA helps to establish a preoperative diagnosis of malignancy. The submandibular salivary (Wharton’s) duct runs forward from the deeper portion of the gland under the mylohyoid muscle to the ﬂoor of the mouth. none Ͼ 6 cm in greatest dimension N3 Metastasis in a lymph node Ͼ 6 cm in greatest dimension Distant metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastases M1 Distant metastasis AJCC ϭ American Joint Committee on Cancer. Proper evaluation of these nerves is extremely important in the management of malignant neoplasms of the submandibular gland. The three nerves in close proximity to the submandibular gland are the lingual. help to distinguish between salivary and nonsalivary (lymph node) pathology when a tumor is located in the region of the tail of the parotid.
Mucoepidermoid carcinomas are more common and constitute approximately 44% of parotid malignancies. Patients who have undergone inadequate local excision or enucleation are prone to local recurrence. and the diagnosis of Warthin’s tumor can be made easily with FNA cytologic analysis. however. Generally. With the increasing incidence of the acquired immunodeﬁciency syndrome (AIDS) and human immunodeﬁciency virus infection. The risk of malignant transformation is extremely small. as it appears to produce excellent results. The long duration of the mass (4–6 months). ﬂeshy. the histopathologic appearance of these tumors has been described as Swiss cheese-like. Thus. surgical excision may be considered. and surgery essentially will result in enucleation. originates in the periparotid or intraparotid lymph nodes. Occasionally.14 AJCC Stage Grouping for Cancers of the Major Salivary Glands Stage I Stage II Stage III Stage IV T1 T2 T3 T1 T2 T4 T3 T4 Any T Any T Any T N0 N0 N0 N1 N1 N0 N1 N1 N2 N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 AJCC ϭ American Joint Committee on Cancer. This change may signify carcinoma developing in a benign mixed tumor (carcinoma ex pleomorphic adenoma). An important reminder is that any tumor in the parotid area is considered a parotid tumor until proved otherwise. where they may remain dormant for a long time. Malignant mixed tu- . Chicago. Distant metastases also are fairly common. its perineural involvement. which may be cystic. mostly to the lung. They are seen also in patients with AIDS-related complex. facial nerve function can be preserved by careful dissection and separation of the nerve and its branches. and its high incidence of local recurrence. The most appropriate and optimal surgery for benign mixed tumors is superﬁcial or subtotal parotidectomy with dissection and preservation of the facial nerve and its branches. affected patients present with a large mass in the tail of the parotid. if affected patients are symptomatic and have no obvious stigmata of AIDS. involved physicians tend toward conservative treatment that may consist of multiple needle aspirations and close observation. Characteristically. However. and the incidence of lymph node metastasis at presentation is approximately 50%. and the characteristic clinical picture along with the cystic consistency of the mass render the clinical diagnosis relatively obvious. may originate in slow-growing benign mixed tumors [73. also called papillary cystadenoma lymphomatosum.324 CLINICAL ONCOLOGY tumors of the parotid that constitute approximately 1% of salivary gland tumors. The CT scan has been used to document multiple cystic areas and bilaterality. owing to its tendency to local extension beyond the gross lesion. Ten percent of these tumors are multifocal. as the incidence of local recurrence and distant metastasis is small. Radiotherapy has been used in select individuals. which occurs in 1–7% of patients. These tumors originate in the salivary duct epithelium and are classiﬁed as low or high grade. AJCC ® Cancer Staging Manual (5th Edition). and removal of the parotid tumor. which consists of a standard parotid incision. Because the natural history of the disease is still evolving. Philadelphia: Lippincott-Raven. Source: Used with the permission of the American Joint Committee on Cancer (AJCC ®). Most patients present with a solitary. 1997. identiﬁcation of the facial nerve and its branches. 74]. welldeﬁned mass in the superﬁcial lobe of the parotid gland. Table 12. Warthin’s tumor. accounting for approximately 17% of parotid malignancies. a lower-lip split incision and mandibulotomy approach may be required. the tumor may extend into the deep lobe of the gland. Approximately 15–20% of affected patients present with regional lymph node metastases. the history of human immunodeﬁciency virus positivity. Occasionally. Malignant mixed tumors. It accounts for approximately 10– 15% of benign parotid tumors. Oncocytomas are rare. These lesions involve the periparotid and intraparotid lymph nodes. High-grade tumors can invade the facial nerve. lowgrade lesions can mimic benign mixed tumors. Clinically. all affected patients should be brought to the operating room for appropriate surgical intervention. slow-growing benign Malignant Parotid Tumors Adenoid cystic carcinoma constitutes approximately 10% of parotid malignancies. long-standing tumor. and 10% may be bilateral. Excising tumors of the deep lobe of the parotid may be difﬁcult. This tumor exhibits an unpredictable behavior. for a very large deep-lobe parotid tumor. A standard superﬁcial parotidectomy is adequate treatment for low-grade mucoepidermoid carcinomas. benign lymphoepithelial lesions are becoming more common.
In a very few instances. and careful identiﬁcation. the cervical plexus. every effort is made to preserve the nerve. Immediate nerve grafting using cable interposition grafts from the greater auricular nerve. Am J Surg 172:695–697. a deep-lobe parotid tumor can be removed without injuring the branches of the facial nerve. Enucleation of parotid tumors is condemned uniformly and must not be carried out. Generally. In general.15 Involvement of Cervical Lymph Nodes by Metastasis of Primary Carcinoma in Salivary Glands Time of Appearance Initially Subsequently Total Parotid Gland (%) (n ϭ 623) 20 5 25 Submandibular Glands (%) (n ϭ 129) 33 4 37 325 Minor Glands (%) (n ϭ 526) 13 9 22 Source: Data drawn from DJ Kelley. Management of cervical lymph nodes in patients with malignant salivary tumors remains controversial. The incidence of metastases in primary carcinoma of the salivary glands is listed in Table 12. The management of malignant submandibular tumors is complicated by the presence of three important nerves in its vicinity: the ramus mandibularis. These tumors have malignant epithelial and mesenchymal components. The facial nerve may be involved in the malignant pathology. high-stage lesions. and preservation of its branches is crucial. In most instances. a fully functioning facial nerve would be sacriﬁced. Management of the neck in parotid carcinoma. excision of the outer periosteum or even the mandible may be required. such patients are characterized by a long-term history of a benign mixed tumor that suddenly shows rapid growth of recent origin with ﬁxation to deeper structures and skin.Head and Neck Cancer Table 12. A supraomohyoid neck dissection may be carried out as part of the procedure. CA) in the upper eyelid. therefore.15. accounting for 2–5% of malignant salivary gland tumors. 1990. If suspicious lymph nodes are found at surgery. both in terms of surgical approach and in preserving the facial nerve. Block dissection of the submandibular gland entails removal of the entire contents of the submandibular triangle. The standard of management of minor salivary gland tumors remains wide local excision. If the nerve is sacriﬁced. the nerve is wrapped around the lesion. the hypoglossal. The ﬁrst type. dissection. Tumors of the deep lobe constitute a challenge. A nerve that adheres to tumor may be peeled off carefully. may be considered for treatment of high-grade. If the tumor adheres to the mandible. Most tumors are located in the superﬁcial lobe of the parotid gland and can be excised easily and adequately using this operation. They are relatively rare. and the lingual. mors are often divided into two types. The second type is the true malignant mixed tumor or carcinosarcoma. The trend currently is toward conservatism in managing the nerve in surgery for malignant tumors. or the sural nerve may be undertaken if the main trunk or major branches are sacriﬁced. in which case postoperative radiotherapy is warranted. 1996. RH Spiro. Curr Probl Surg 27:775–883. Treatment SURGICAL EXCISION Surgical excision in combination with adjuvant postoperative radiotherapy. if the facial nerve is not paralyzed preoperatively and no direct extension of the disease into the nerve is found at surgery. a modiﬁed neck dissection . tumors involving the hard palate require a full-thickness excision or infrastructure partial maxillectomy with a dental obturator. High-grade mucoepidermoid and primary squamous cell carcinoma are the only subtypes with a substantial risk of nodal metastases. also known as carcinoma ex pleomorphic adenoma. occasionally with ulceration. This procedure avoids exposure keratitis. MedDev. Salivary gland tumors. Elective supraomohyoid neck dissection. though. eye function and eye closure can be improved by implantation of a Gold Weight (Gold Eyelid Implants. Reprinted with permission from JP Shah. if the bulk of the tumor is against the pharyngeal wall. is a carcinoma (usually adenocarcinoma) that develops in a pre-existing benign mixed tumor. Occasionally. Palo Alto. a mandibulotomy approach may be necessary for better exposure of the parapharyngeal area. if indicated. The minimal operation for a lesion involving the parotid gland is a superﬁcial parotidectomy with identiﬁcation and preservation of the facial nerve. Commonly. is the treatment of choice for malignant salivary tumors. JK Ihde. Generally.
) Table 12.807 patients. mucoepidermoid carcinoma.807 patients. deep-lobe malignant tumors. tumors of the submandibular gland are more aggressive than are parotid tumors.. Inc. a subsidiary of John Wiley & Sons. Head Neck Surg 8:177–184.12 (A) Signiﬁcant differences in survival were observed when previously untreated patients with salivary tumors were grouped according to the clinical stage (p Ͻ . Grade is also an important prognostic factor: The 10year survival rate for low-grade tumors is 90% compared with 25% for high-grade tumors (see Fig. postoperative radiotherapy must be considered in high-stage lesions. (B) Survival differences were similar in patients who had adenocarcinomas. Inc. Histologic type of the tumor also has an impact on prognosis: Acinic or low-grade mucoepidermoid tumors have a better prognosis than adenocarcinoma. and 22%. Table 12.0001). Prognosis Tumor stage remains the most important prognostic factor in salivary gland neoplasms. a subsidiary of John Wiley & Sons. The overall 10-year survival rates for stages I through III are approximately 90%. as indicated. Because the incidence of local recurrence in adenoid cystic carcinoma is high. Salivary neoplasms: overview of a 35-year experience with 2. and tumor spillage at surgery. RADIOTHERAPY Indications for radiotherapy in treating salivary gland cancer include advanced inoperable cancer. or squamous cell carcinoma and were analyzed by histologic grade (p Ͻ . high-grade.. as are mi- may be completed. malignant mixed tumor.16 Determinate Cure Rates in Patients with Malignant Tumors Parotid Gland (%) (n ϭ 623) 55 47 40 33 Submandibular Glands (%) (n ϭ 129) 31 22 15 14 Minor Glands (%) (n ϭ 526) 48 37 23 15 Interval (Yr) 5 10 15 20 high-stage primary tumor. positive margins after surgery. from RH Spiro. lymph node metastases. 65%. 1986. 12. 1986. Head Neck Surg 8:177–184. or squamous cell carcinoma..16 shows the determinate cure rates in patients with malignant tumors of the three types of salivary glands. The presence of grossly palpable nodes at initial evaluation requires modiﬁed or radical neck dissection.12).12) . Inc. Inc..326 CLINICAL ONCOLOGY A 100 B Stage I Low 75 Percent Survivng 50 Stage II Intermediate 25 High Stage III–IV 0 5 10 15 20 Years 5 10 15 20 Figure 12. The use of fast neutrons for treating advanced salivary gland neoplasms has been under investigation and has shown much promise. 12. (Reprinted with permission of Wiley-Liss. adenoid cystic. respectively (Fig. Salivary neoplasms: overview of a 35-year experience with 2. . Generally. Source: Reprinted with permission of Wiley-Liss.0001). from RH Spiro.
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(Image provided by Susan Muller.) CD image 12. A loose network of stellate cells forms the center of the mass. click on each thumbnail to see a full screen image. (Image provided by Susan Muller.) 7 . DMD. (Image provided by Hunter T.) Gingival squamous cell carcinoma.) CD image 12. (Image provided by Susan CD image 12. DMD.09 Squamous cell carcinoma of nasal cavity. (Image provided by Susan Muller. Close each full screen image to return to the composite.07 Floor of mouth squamous cell carcinoma. (Image provided by Susan Muller. The laryngeal mucosa is extensively replaced by necrotic cancer. DMD.) CD image 12. (Image provided by Susan Muller.11 Vocal cord squamous cell carcinoma.) CD image 12.04 Oral squamous cell carcinoma with perineural invasion.Additional Images Chapter 12 Instructions: Click on each figure legend below to bring up a composite image (thumbnail image or images and the figure legend combined). Cytologic atypia is absent.06 Verrucous carcinoma. rather than infiltrative.05 Verrucous carcinoma of hard palate. There is marked hyperkeratosis and a pushing.) CD image 12. DMD. Close the composite to return to this screen.08 Ameloblastoma.02 Muller. DMD. CD image 12. DMD. When the composite appears on the screen. DMD. DMD.) CD image 12.01 Erythroleukoplakia of gingiva and tongue.) CD image 12. pattern of invasion with bulbous rete ridges.12 Squamous cell carcinoma of larynx. (Image provided by Susan Muller. Hardy. DMD. (Image provided by Susan Muller.10 Supraglottic squamous cell carcinoma. (Image provided by Susan Muller. (Image provided by Susan Muller. DMD.) CD image 12. Epithelium at the border of the tumor shows polarization with nuclei oriented away from the basement membrane.) CD image 12.03 Invasive oral squamous cell carcinoma. MD. (Image provided by Hunter T. Hardy. MD. See the “How To Use This CD-ROM” file for more information.) CD image 12.
20 Fine needle aspiration of acinic cell carcinoma.) CD image 12. MD. basophilic cytoplasm. (Image provided by Susan Muller. MD. (Image provided by Ted Gansler. (Image provided by Ted Gansler. The neoplastic cells have granular. MD. DMD.18 Low grade mucoepidermoid carcinoma. DMD. This Diff-Quikstained direct smear demonstrates metachromatic (violet) staining of hyaline globules.13 Benign mixed tumor (pleomorphic adenoma).) CD image 12. In contrast. This neoplasm contains both epithelial (left side of image) and mesenchymal (right side) components. The stellate mesenchymal cells are surrounded by blue-gray-staining myxoid matrix. Differentiation is predominantly glandular in low grade lesions such as this one.) 8 . Lumina contain mucin. which are surrounded by the neoplastic cells. Both papillary and glandular patterns are present.15 Adenoid cystic carcinoma arising in minor salivary gland of hard palate. (Image provided by Susan Muller. (Image provided by Ted Gansler.) CD image 12.) CD image 12.) CD image 12. MD. This Diff-Quikstained direct smear demonstrates acinar formation. Columnar cells with granular eosinophilic cytoplasm cover the fibrovascular stroma with focal lymphoid infiltration.CD image 12.16 Adenoid cystic carcinoma with perineural invasion. (Image provided by Ted Gansler. They are arranged in small acini.17 Fine needle aspiration of adenoid cystic carcinoma. MD. The epithelial cells are arranged in nests with focal gland formation. (Image provided by Ted Gansler. which lack the myoepithelial cells of normal salivary acini.19 Acinic cell carcinoma. Some of the glandular spaces are cystically dilated.14 Warthin’s tumor (papillary cystadenoma lymphomatosum). The absence of myoepithelial cells and of the normal lobular architecture of acini and ductules distinguishes these neoplastic acini from normal salivary gland tissue.) CD image 12. DMD.) CD image 12. Cellular pleomorphism is slight. (Image provided by Susan Muller. the squamous component predominates in high grade mucoepidermoid carcinomas.