Head & Neck SCC (HNSCC) Over View

Dr Shafiq Chughtai PGT SU II

Regions 
Skin  Oral Cavity (lip ,oral cavity , oral tongue , floor of
mouth , alveolus and gingiva , retromolar trigone , buccal mucosa) 

Phyranx (naso , oro , hypo)  Lyranx  Nose and Para nasal sinus  Ear and temporal bone

Skin SCC 

Aetiology 
Solar Radiation  UV ± A , UV ± B , UV ± C.  Fair skin , melanin content  High risk at equater then lattitudes  HPV (perinium)

Clinical Features 
Red , scaly , ulcerated patch of skin  Types  Protuberent  Infilterative  Pain along the distribution of nerve (perineural invasion)  Ulcerated growth --- everted edges 

Head and neck SCC have better
prognosis then else ware in the body 

Diagnostic Inx is excisonal biopsy

Management

Non Cuteneous HNSCC

Aetiology 
Tobacco 
1.9 x males , 3x females  40% have recurrance of malignacy if they continue to smoke as compared to 6 %  Reverse smoking 47x hard palate 

Alcohol 
1.7 x males with 1-2 drinks / day 1- 

Betal nut chewing , HPV .  Solar radiation for lip Ca (lower lip)  Immunocompromised 
Renal transplant 30 x risk  AIDS 

p53 mutations are blamed in > 50% of
HNSCC 

Most of the pts are elderly with co morbid
states and malnutrioned

Synchronous Vs Metasynchronous 
Over all rate of 2nd HNPCC coexisting in same
patient is 14% 

If found within 6 months Synchronous  If found after 6 months Meta synchronous, 80%  Cessation of drinking and smoking is mandatory
to reduce syn/metasyn lesions (40% vs 6 %)

Investigations 
CT , MRI  Pan Endoscopy (inspection and biopsy) 
Lyrangeoscopy  Esophagoscopy  Bronchoscopy

AJCC Staging

Oral Cavity 

Extends from vermilion border to hard /soft
palate junction superiorly , circumvallate papillae inferiorly and anterior tonsillar pillars laterally 

Has 7 sites

Oral Regions

LIP

ORAL TONGUE

FLOOR MOUTH

ALVEOLUS / GINGIVA

RETRO MOLAR TRIGONE

BUCCAL MUCOSA

PALATE

Lip
50 Peak incidence 50-70 yrs , more in fair skinned. 

88-98% lower lip , 2-7% upper lip , 1% oral 882commissure 

Clinically ulcerated , crusty lesion which
fails to heal over a period of time. 

Nodal mets occour to submental /
submandibular nodes in less then 10% 

Management is same as cuteneous
HNSCC.

Reconstruction 
Estlander flap 

Karapandzic labioplasty

Estlander flap

Karapandzic labioplasty 

Bad prognostic markers 
Age less then 40 yrs , maxilla or mandibular involvement , perineural invasion , Upper lip 

5 yr survival is 90% in node ±ve and 50%
in node +ve disease.

Oral Tongue 
Exophytic / ulcerated mass on ventral and
lateral surface of tongue. 

Lingual nerve (impaired taste) &
hypoglossal nerve(tongue deviation)

Management

Reconstruction 
Surgery , in T3/T4 involves partial or total
glossectomy 

Palliative tracheostomy and feeding
jejunostomy may be indicated in advanced caes

Floor of Mouth 
Anterior tonsillar pillar to frenulum
anteriorly , inner surface of mandible to ventral surface of tongue 

Muscular involvement ---mastication and ---mastication
articulation problems 

Anterior and lateral extension involves
mandible 

Submandibular and sublingual glands are
commonly involved 

Treatment is similar to tongue CA 

Resection may require segmental
mandibulectomy

Alveolus / Gingiva 
Alveolar mucosa is tightly adherent to
underlying bone , bony involvement is common. 

MRI is best to assess bony involvement 

Rx principal is same as tongue Ca 

Access is via anterior mandibulectomy /
segmental mandibulectomy

Retromolar trigone 
Posterior inferior alveolar ridge to inner
surface ramus of mandible 

Bone involvement common due to lack of
soft tissue 

Masatter ----trismus , mandible , ----trismus
orophyranx , base of skull 

Rx is marginal / segmental
mandibulectomy with reconstruction 

Ipsilateral ELND is always done due to
high risk of mets. 

Thus mandibulotomy is used to assess
intra oral lesions specially floor of mouth , alveolus and gingiva and retromolar trigone lesions. 

Rx principal ~ as Ca tongue.

Buccal mucosa 
Inner surface of lip to alveolar ridge  Drains primarily to submandibular group  Rx principal same  Recon involve multidisciplinary approach

Palate 
Semi lunar area ± between inner surface
superior alveolar ridge 

Reverse smoking 47 X  Greater palatine nerve involvement is very
common so biopsy is madatory 

Surgery 
With out bony involvement , wide local excision 

With bony involvement ± multidisciplinary approach + dental prosthesis

Phyranx

PHYRANX

ORO
(soft palate - valacullae)

NASO
Post nasal septum To plane hard / soft palate

HYPO
Valacullae To Lower border cricoid

Naso phyranx 
EBV and smoking  Clinically 
   Nasal obstruction Epistaxis Ottiti media , Otalgia Base of skull ---V,IX,X palsies ---V,IX,X 

Surgery 
Transpalatal  Transmaxillary  Anterior cranial fossa approach 

Chemotherapy for early disease 
Cisplatin + 5FU 

Metastatic disease 
Radiotherapy

Orophyranx 
Contains base of tongue , soft palate ,
uvula , tonsillar pillar , phyrangeal tonsils and phyrangeal walls 

Exophytic / ulcerated patteren common 

Clinically 
    Tumor fetor (TNF) Muffled / hot potato voice Dysphagia , malnurition Otalgia (IX,X) Trismus (ptyregoid involvement) 

Nodal mets in 50% at Px 

Drains to Level II,III,IV,V group +
retro/paraphyrangeal nodes

Managemant 

Cammando procedure 
Classically described for orophyrangeal tumors  Lateral wall oral phyranx , soft palate , tongue base , ramus mandible , RND .  Nowadays MRND is used in place of RND. 

When tongue base is excised , retaining
the lyranx , chances of dysphagia and aspiration are very high. 

Lyrangectomy is done or lyranx
suspension procedures are done which are very complex.

Hypophyranx / Cervical Esophagus 
Worst prognosis of HNSCC  ¾ Px with B/L paratracheal
lymphadenopathy 

Lyrangeo-phyrangeo-esophagectomy is Lyrangeo-phyrangeodone in localized disease. 

B/L neck dissection is rarely indicated as
disease is often incurable at Px 

In cervical esophagus , cricophyrangeous
involvement mandates lyrangectomy.

Lyranx 
Extends from epiglottis to lower end of
cricoid cartilage 

90% of HNSCC  Soft tissue component of lyranx is
seperated from surrounding by fibroelastic memberanes limiting Ca spread 

Region 
Supra glottic ± epiglottis to true vocal cords  Glottic ± true vocal cord  Infraglottic ± true vocal cord to lower end cricoid cartilage 

Clinically 
Supraglottic ± chronic sore throat , dysphonia , dysphagia  Glottic ± hoarseness of voice (early) , airway obstruction (late)  Infraglottic ± stridor , pain , neck mass. 

Supraglottic ± drains along sup lyrangeal
artery via thyrohyoid membrane to subdiagastric / superior lyrangeal nodes 

Glottic / infra glottic ±drains along cricoid
ligament to prelyrangeal , pre tracheal and deep cervical nodes 

Early tumor 
Confined to lyranx , without vocal cord fixation 

Late tumor 
Extends outside lyranx  Cord fixation 

Early tumor 
Megavoltage radiotherapy / laser ablation 

Late tumor 
Supraglottic ± partial lyrangectomy in most  Glottic / infra glottic --- total lyrangectomy  Radiotherapy / chemotherapy 

After lyrangectomy permenant tracheostomy is
done and continuity of digestive tract restored. 

Swallowing rehabilitation  Speech rehabilitation 
Electro lyranx  Blom singer valve with tracheo Esophageal fistula for esophageal speech

Nose & PNS 
Initial symptoms mimic sinositis , nasal
obstruction . 

Late , orbital extension can cause
proptosis / blindness , maxillary sinus tumors can cause loosening of teeth 

Evaluation of cavernous sinus , cribriform
plate and dura is mandatory 

Flexible naso scope , CT and MRI are
diagnostic / staging tools 

Multidicipline surgical team « OMF , ENT
, Neuro surgeons 

Radiotherapy is given post
operatively.Chemo has limited role

Summary

Neck 

Presence of nodal mets reduce survival by
50% 

Oral cavity / lip drains into level I , II , III  Orophyranx , hypophyranx , lyranx drains
into II , III , IV. 

Hypophyranx , cervical esophagus ,
thyroid drains upto level VII

Neck dissections 
Elective  Radical  Modified radical  Selective 

Elective lymph node dissection is done in
node ±ve cases for prophylactic purposes 

Radical lymphnode dissection removes
level I-V + SCN , IJV , XI I- 

RND had considerable morbidity  Removal of one IJV increases chances of
raising ICP by 3x , if both removed , by 5 X. 

Removal of CN XI causes drooping of
shoulder and limited movement at shoulder joint. 

Modified radical nodal dissection is ~ to
RND in nodal clearence except one or all of SCM , IJV , CN XI is preserved. 

Selective nodal dissection preserve
lymphatics as well as SCM , IJV , CN XI. 

Selective LND 
Supra omohyoid (oral cavity) , level I ± III  Lateral neck (lyrangeal malignancy) II ± IV  Posterolateral neck (thyroid) II - V

Management

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