Thaufiq Boesoirie

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TUMOR
BENIGN
• TYPE
MALIGNANT
• SIZE
• LOCATION
• METASTASIS
-LOCAL
-DISTANT
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• ETIOLOGY
• SYMPTOMS
• SIGNS
• PHYSICAL EXAMINATION
• LAB & RAYS
• PATHOLOGY EXAMINATION
• THERAPY

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ETIOLOGY (General)

• IONISING RADIATION
• UV RADIATION
• AIR POLLUTION
• PROFESSION FACTOR
• FOOD
• IATROGENIC CHEMICAL
• HORMONAL
• TOBACCO
• SEX & REPRODUCTIVE LIFE
• CIRCUMCISION
• PARASITES
• GENETIC
• IMMUNODEFICIENCY
• VIRUS

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 RADIATION SOURCES

• RADIOACTIVE MINERAL MINING

• COSMIC RAYS

• RADIATION FROM MEDICAL AQUIPMENT

 X RAY
 THOROTHRAST
 Ra 224

• ATOM BOM

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PROFESSION
• TAR

• MINERAL OIL CONTAINING DERIVAT ATHRACENE

• ANILINE : - BENIZIDINE
- NAPHTHYLAMINE
- AMINOBIPHENYL
• ASBESTOS

• BENZENE

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V I R U S
Human t cell leukemia v (htl.V-i)
Hepatitis b.V. (Hbv)
Human papilloma v (hpv 16, 18, 31)
Epstein-barr.V (ebv)

Chemical Carcinogenesis
- V. Chlorida
- Aflatoxin

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“CANCER” DEVELOPMENT

PHASE :
- INDUCTION 15 – 30 tahun
- IN SITU 5 – 10 tahun
- INVASI 1 – 5 tahun
- DISSEMINATE 1 – 5 tahun
- SUBSTANCES INITIATION
PROMOTION
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CHROMOSOME CHANGES BECAUSE OF :

1. RECIPROCAL TRANSFORMATION
2. ADDITION OF GENS IN SPECIFIC AREA
OF CHROMOSOM
3. NON RECIPROCAL CHANGES
• DELETION
• ADDITION

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EXAMPLE

AD.1 : - CHRONIC MYELOID L

Between Chromosom 22 - 9
- ACUTE PROMYELYTIC L
BetweenChromosom 15 & 17
AD.2 : 11.q 13 is locus for
ONCOGENE : INT 2
HST 1
bCL 1
PRAD 1
AD.3 : - DELETION 3p, Small Ca Paru
- DELETION of 3p 21, 3p24.

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TUMOR & GEN p.53

• GEN p.53 & TUMOR

• SITE GEN p.53
• FUNCTION GEN p.53
• MUTATION GEN p.53 & ITS CONSEQUENCES

* FAMILIAL MULTIPLE TUMOR

ONCOGEN, PROTOONCOGEN

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 Chief complaint of the patient with tumor of
the head and neck area
1. Lump/Lession
2. Nasal Obstruction
- nasal bleeding
- nasal deformity
3. Proptosis
- Blurred vission
- Double vission
Opthalmoplegia
4. Ear : - obstruction
- hearing impairment
- blood/fluid from ear
- pain
- ear that pushed out
5. Face : - numb/pain
- N VII paralysis 12
6. Mouth and Pharynx
- lump in the longue
- pain
- deformity
- bleeding
- food goes into nose
- trismus
7. Larynx
- hoarse
- dyspnue
- aspiration
- haemaptae
8. Esophagus : - lump in the throat
9. Lung : - cough
- haemaptae
- dyspnue
10.Thyroid : salivary gland
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 Signs of malignant tumor in head and neck area
Ear : - middle ear mass
- external mass
- middle ear fluid
- bleeding
Nose : - deformity
- nasal mass
- bleeding

Face : - N.VII paralysis

- pain/numb
- supraorbital
- mental
Eye : - N.VI paralysis
- opthalmoplegia
- blurred vision
- exopthalmus + proptosis
Mouth : - mass
- lesion
- stiff tongue
- trismus
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Pharynx : - Nasoph soft
mass firm
bleeding
eustachea tube obtruction

- Oro
pharynx
Hypo
- Mass
- lesion

Larynx : - Mass
- Vocal cord mobility
- deformity
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Lab : - Hb, leuco, periferal blood smear
- Fasting blood sugar;
- FL, FG
- Lung function
- Serum protein
- HB, Ag; HN
- Thrombocytes : chal, treglyc

Bleeding time
Clotting time

ECG ; thorax X ray PA

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X Ray : Ear ; Schuller, Stenver’s
transorbital; polytome
Nose & SPN : -Water’s
-Caldwell
-Submentovertex
-Lateral PNS
Nasoph : - Schedel basis/Submentovertex
Oro; Hypo ph & Larynx :
- extension position of lat.soft tissue
- tomogram larynx
- laryngogram

Esoph : esophagogram
Tracheo bronchial : chest X Ray
- CT : - axial
- Coromal
- MRI 17
Material and Pathology tissue: -Needle biopsy
-Excisional biopsy
-Incisional biopsy

Extension & metastasis of malignant head and neck tumor

Metastasis area of malignant head and neck tumor
- lymphogen (Ca)
- Haematogen (Sa)
- Percontinuitatum
Lymphogen : mucosa tumor
epithelial tumor

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 AREA METASTASIS FROM :
Nose :
Paranasal sinus:
Nasopharynx :
Oropharynx :
anterior
Mouth :
posterior

- Base of the tongue

- Hypopharynx
- Esophagus

Skin Sq cell Ca
Melanoma 19
THERAPY DEPENDS ON :

•SIZE & EXTENSION,TYPE

•EXOPHYTIC/INFILTRATION
•INVOLVING THE MUSCLE / BONE
•POSSIBILITY OF COMPLETE RESECTION
•POSSIBILITY OF METASTASIS
•GENERAL CONDITION
•PRESERVATION : - SPEECH
- SWALOWING
•SOCIAL STATUS
•CAPABILITY OF SURGEON, RADIOTHERAPIST
AND CHEMOTHERAPIST

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THERAPY

• SURGICAL + ND
• RADIATION
• CHEMOTHERAPY
• CRYO SURGERY, LASER
• IMMUNOTHERAPY
• COMBINATION

 PURPOSE : - FOR CURE

- PALIATIVE
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AREA TUMOR
HEAD AND NECK TUMOR

• NOSE AND PARANASAL SINUS

• EAR
• MOUTH
• PHARYNX  NASOPHARYX
 OROPHARYX
 HYPOPHARYX
• LARYNX
• CERVICAL ESOPHAGUS
• SALIVARY GLANDS
• THYROID & PARATHYROID
• VASCULAR TUMORS
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CANCER H & N (Distribution)
• ORAL CAVITY 40%
• LARYNX 25%
• PHARYNX 15%
• SALIVARY GL 7%
• OTHERS 13%

 Ca H & N ≈ 10% ALL MALIGNANCY

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STAGING (General)

T N M

I. T1 N0 M0

II. T2 N0 M0

III. T3/4 N0 MO
ANY T N1/N2 M0

IV. ANY T N3 M0
ANY T Any N M1

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LIMPHADENOPATHY COLI (NECK)

UICC

AJC

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Regional Lymph Nodes
NX : Neck lymph node status unknown
N0 : No metastasis
N1 : Metastasis one side ipsi lateral LN 3 cm
N2a : Metastasis one side ipsi lateral LN> 3 cm,
< 6 cm
N2b : or multiple ipsi lateral LN, < 6 cm
N2c : or bilateral/contralateral LN, < 6 cm
N3 : Metastasis pada regional LN, > 6 cm at
largest diameter
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27
NOSE TUMOR AND PARANASAL SINUS

BENIGN : - OSTEOMA
- OSSIFYING FIBROMA
- FIBROUS DYSPLASIA
- PAPILLOMA
- HEMANGIOMA
- LYMPHANGIOMA
- NASOPHARYNX ANGIOFIBROMA

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 NOSE AND PARANASAL SINUS
(Type and frequency of malignant)

• SQUAMOUS CELL Ca ( 57% )

• ADENOID CYSTIC Ca
• ADENO Ca. ( 18% ) : UNDIF CELL Ca 10%
• SARCOMA : - SPINDLE CELL Ca
(RARE) 15% - ROUND CELL Ca
- OSTEO Sarcoma
- CHONDRO Sarcoma
CHILDREN : HIST & RHABDOMYO Sarcoma

PRIMARY SITE
• ANTRUM 60%
• NOSE 15%
• ETHMOID 20%
• FRONTAL & SPH 1%
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MALIGNANT TUMOR
SUPERIOR SINUS (AREA)

• FRONTAL
• ETHMOID
• SPHENOID
• MAXILLO ETHMOID
• T1 : 1 AREA
• T2 : 1 REGION
• T3 : > 1 REGION
• T4 : SKIN, SKULL BASE, NASOPHAR

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MAXILLARIS SINUS

• SUPERIOR
• INFERIOR
• MEDIAL
• LATERAL

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Maxillaris Sinus
Tx : Unknown primary tumor
T0 : No primary tumor
T1S : Ca in situ
T1 : Tumor confined to antral mucosa
without erosion/destruction
T2 : Tumor with erosion /destruction of
palatum durum or meatus media or both

T3 : Tumor has invaded : cheek skin or posterior

wall,floor of the orbital or anterior of ethmoid

T4 : Tumor has invaded orbita or area cribosa/

ethmoid posterior/sphenoidalis sinus/naso-
pharynx/soft palate/pterygomaxillary/temporal
fosa/skull base.
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 NOSE TUMOR
LOCATION

• ROOF + CONCHA SUP

• LATERAL HIDUNG + C. INF & MEDIA
• NASAL SEPTUM
• NASAL FLOOR

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THERAPY :
( Nose & Paranasal sinus malignat tumor)
1. OPERATION
P
- MAXILLECTOMY
T
+ ORBITAL EXENTERASI
- LATERAL RHYNOTOMY
- ANTERIOR SKULL BASE RESECTION
- FRONTAL BONE RESECTION
2. RADIO THERAPY : 6.000 Rad
- PRE OP
- POST OP.
3 3. CHEMO THERAPY : PALLIATIVE
5 years : 30-40 %
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MOUTH TUMOR AND OROPHARYNX
BENIGN : - HEMANGIOMA
- PAPILLOMA
- LINGUAL Thy
MALIGNANT :- SQUAMOUS CELL CA
- ANAPLASTIC
- AD. CA
RARE
- ADENO CA
- SARCOMA : - SPINDLE CELL
- MYXOMA
- M. LYMPHOMA
- RHABDOMYOSAR
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MOUTH TUMOR :
BENIGN
 MALIGNANT
LOCATION :
-LIP
- BUCCAL MUCOSA
- LOWER ALVEOLUS
- UPPER ALVEOLUS
- RETROMOLAR TRIGONUM
- FLOOR OF THE MOUTH
- HARD PALATUM
- 2/3 ANTERIOR OF THE TONGUE

STAGING & THERAPY

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 LIP TUMOR

 TIS
 T0
 T1 2 CM
 T2 2-4 CM
 T3 > 4 CM
 T4 TUMOR INVASION INTO
ADJACENT STRUCTURE
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 Mouth & Oropharynx
T1S - Ca in situ
T1 - Tumor < 2cm at largest diameter
T2 - Tumor > 2cm, < 4cm
T3 - Tumor > 4cm with antral invation
T4 Mulut - Massive > 4cm with invaded antral ,
M Platerygoid, base of the tongue or neck
skin
T4 Oropharynx : > 4cm with invaded the bone,soft
tissue or muscle of the tongue.

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 PHARYNX :

• NASOPHARYNX

• OROPHARYNX

• HYPOPHARYNX

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Q NEOPLASMA NASOPHARYNX
- HISTO : - UNDIFF. CA
- NON KERATINISNG CA
- SQUAMOUS CELL CA.
- CHORDOMA,
- CRANIOPHARYNGIOMA
- TH/.

Q OROPHARYNX
- BASE OF THE TONGUE
- ARCUS FAUCEUM
- TONSIL + PILLAR
- PHARYNGEAL WALL

- TH/.
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Nasopharynx
T1S : Ca in situ
T1 : Tumor confined to one location in nasopharynx
or tumor cannot be seen only biopsy +

T2 : Tumor confined to two location

( posterosuperior & lanteral wall or both )

T3 : Tumor with extention to the nose or oropharyx

T4 : Tumor had invaded at skull or cranial nerve

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Q HYPO PHARYNX
• PIRIFORM SINUS
• POST CRICOID
• POST PHARYNX WALL

TIS
T0
T1 : 1 LOCATION
T2 ; EXTEND TO OTHER LOCATION
FIXATION (-)
T3 : EXTEND TO OTHER LOCATION
+ FIXATION
T4 : EXTENSION INTO ADJACENT
STRUCTURE

 TH/.
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EAR NEOPLASMA
 AURICLE
 CANAL - ANT.
- POST
 MIDDLE EAR & MASTOID

TH/.

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 VASCULARY TUMOR OF
THE HEAD & NECK
CHEMODECTOMA
10% MALIGNANT
 5% LOCAL METASTASIS
 5% DESTANT METASTASIS

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LARYNGEAL TUMOR

BENIGN : - POLYPS
- REINKE’S EDEMA
- PAPILLOMA
- RETENTION CYST
- CHONDROMA

LEUCOPLACHIA : Grade 1,2,3.

MALIGNANT : - SQUAMOUS CELL CA.

- CHONDRO SARCOMA

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 MALIGNANT TUMOR OF
THE LARYNX
GLOTTIS 65%
SUPRA GLOTTIS 30%
SUB GLOTTIS 5%
 STAGING
 TH/.

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Larynx

Supraglottic
T1S : Ca in situ

T1 : Tumor confined to the original place with

normal movement

T2 : Tumor extend to adjacent supraglotis area

without fixation

T3 : Tumor still confine to the larynx with fixation

or extension or both to postcricoid,medial
pryfrom sinus wall or to pre epiglotic space

T4 : Massive tumor that had invaded to oropharynx

soft tissue of the neck or destruction from
thyroid cartilage.
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 Glottic

T1S : Ca in situ
T1 : Tumor confine to vocal cord with
normal mobility

T2 : Extended to supra / subglotic or both with

normal / abnormal vocal cord movement

T3 : Tumor confine to the larynx with fixation

of vocal cord

T4 : Massive tumor with destruction of thyroid

cartilage or extra larynx extension or both
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Subglotis

T1S : Ca in situ
T1 : Tumor confine to subglotic area
T2 : Tumor extended to vocal cord ,normal
mobility/impairet
T3 : Tumor with cartilage destruction or
extra larynx extension or both

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 THERAPY

 SURGERY
 RADIO THERAPY
 CHEMO THERAPY
SURGERY :
- DECORTICASI
- CORDECTOMY
- VERTICAL/HORISONTAL PARTIAL LARYNGECT.
- TOTAL LARYNGECTOMY

REHABILITATION :
- SPEECH
- SOCIAL
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NEOPLASMA GLANDULA THYROID & PARATHYROID

 WORK UP.

 THERAPY

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 THYROID CA

• 1% dari All Ca.

• Age : - 7-20 y
- 40-65 y
• MALE: FEMALE = 1 : 2
• 25% DARI NODULAR GOITER

• IRRADIASI RISE ¼ NODULE, ¼ MALIGN.

• PAPILLARY (60%)
- MULTICENTRIC 50% PD C. Lateral

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 FOLLICULAR
 UNIFOCAL
 METASTASIS TO NECK
( & VASCULAR)
 PAPILARY & ALVEOLARY ADENO Ca
 > MALIGNANT PD ORANG TUA

 MEDULLARY Ca,
 FROM C Cells Calcitonin MEA
 L. NODE : EARLY METASTASIS

 UNDIF THYROID Ca : 10%

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Thyroid Gland

TX : Tumor cannot be assessed

T0 : No primary tumor
T1 : Tumor < 1cm in largest diameter but
still confine to the thyroid
T2 : Tumor > 1 cm, < 4 cm
T3 : Tumor > 4 cm still confine to the thyroid
T4 : Any size of tumor with extra thyroid
extension

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Staging of Malignant Thyroid Tumor
Papillary & Follicular
Under 45 years old
stage I : any T, any N M0
Stage II : any T, any N M1
Over 45 years old
stage I T1 N0 M 0
stage II T2 N0 M 0
stage III T3 N0 M 0
any T N 1 M0
stage IV any T any N M1

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Medullary

Stage I T1 N0 M0
II T2 N0 M0
T3 N0 M0
T4 N1 M0
III any T N1 M0
IV any T, any N M1

Undifferentiated
all stage IV
any T, any N,any M

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5 y SURVIVAL RATE

 PAPILLARY : 80-90%
 FOLLICUL. (ALV) : 50-70%
 MEDULLARY : 30-40%
 ANAPLASTIC : 5%

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 SALIVARY GLAND TUMOR

 PAROTIS
 SUB MAXILLARY GLANDS
 SUB LINGUAL GLANDS
• BENIGN
• MALIGNANT
 SMALL SALIVARY GLANDS TUMOR

 TH/.

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AP MALIGNANT TUMOR
SALIVARY GLAND
 ADENO Ca
 MUCO EPIDERMOID Ca
 SQUAMOUS CELL Ca
 ADENO CYSTIC
 ACINIC CELLS
 MALIGNANT MIXED
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Parotic Gland

TX : Tumor cannot be assess

T0 : No primary tumor
T1 : Tumor < 2cm at largest diameter
T2 : Tumor 2-4 cm at largest diameter
T3 : Tumor antara 4-6 cm at largest diameter
T4 : Tumor > 6 cm

Are classified into :

a. without local extension
b. with local extension

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 CARCINOMA (Prognosis)
 LIP.LOWER : 54 – 85%
 TONGUE –2/3 ANTERIOR : T1 – T2 70-80%
 30%
 FLOOR OF THE MOUTH : No LN  70%
+ LN  30%
 TONSILS  75%
 20%
 SOFT PALATE  60 – 70%
 20%
 NASOPH  70%
 35%
 HYPOPH 5y 15 – 45%
 PAROTIS 5y 30 – 50%
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TERIMA KASIH

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