HEAD AND NECK CANCER
INTRODUCTION
90 to 95% are SCC ; Early lesions may be asymptomatic thus Dx may be delayed ; 6th commonest
malignancy world wide
EPIDEMIOLOGY

6th, 7th and 8th decades of life.

es with age. M>F 4:1.

1/3 die from their disease ; 5Y disease free cure rate = 30-40% Incidence slowly rising ; death rate stable
over the last 30 years.
AETIOLOGY
1. Tobacco
a. 5x increase risk
b. 40% of pts who continue to smoke will develop a 2nd metachronous lesion c.f. 6% of those
who stop will.
2. Alcohol
a. 15x increase risk if smokes and drinks
3. Chronic irritation (dentures)
4. Poor oral hygiene
5. Chronic infection (Candidiasis, repeated HSV infections, EBV)
6. Occupational agents (toxic irritants: nickel, chromium, wood workers)
7. Nutritional factors
a. Dietary carotenoids, fruits/veges protective
8. Side effects of radiotherapy
9. Hereditary factors
10. Oncogenic viruses
a. human papillomavirus in laryngeal SCC
b. EBV in nasopharyngeal carcinoma
11. Betel nut chewing (India)
12. Chronic syphilis  atrophic glossitis  Ca
13. Plummer-Vinson syndrome (dysphagia, mucosal atrophy in middle aged Scandinavian women  Fe
def anaemia and oes Ca, buccal Ca, tongue Ca)
“Field carcinogenesis”- 5-7% of head and neck cancers will have a synchronous cancer.
SITES
1. Oral cavity
40%
2. Pharynx (nasopharynx, oropharynx, hypopharynx)
15%
3. Larynx (supraglottis, glottis, subglottis)
25%
4. Paranasal air sinuses (maxillary, ethmoid, frontal and sphenoid)
5. Major salivary glands
17%
6. Other sites
13%
LYMPH NODE LEVELS
I. Submandibular, submental

Ia (submental) Between mandible and the 2 anterior belly of digastrics

Ib (submandibular) Mandible and ipsilateral anterior/posterior digastric
II. Upper jugular (jugulodigastric)

skull base to bifurcation of carotid artery/hyoid bone

posterior border of SCM to lateral border of sternohyoid

IIa anterior to the spinal accessory nerve

IIb posterior to spinal accessory nerve
III. Mid jugular

Hyoid bone to omohyoid muscle/ cricothyroid notch
IV. Low jugular

from the omohyoid muscle superiorly to the clavicle inferiorly
V. Posterior triangle

posterior boundary is the anterior border of the trapezius muscle, the anterior boundary is the posterior
border of the sternocleidomastoid muscle, and the inferior boundary is the clavicle.

Va superior to accessory nerve

Vb inferior to accessory nerve
VI. Anterior compartment

level of the hyoid bone superiorly to the suprasternal notch inferiorly

On each side, the lateral boundary is the medial border of the carotid sheath.

Contains perithyroidal lymph nodes, paratracheal lymph nodes, lymph nodes along the recurrent
laryngeal nerves, and precricoid lymph nodes.
LEUKOPLAKIA
A clinical term only – WHO definition: a white patch or plaque that cannot be characterized clinically or
pathologically as any other disease.
microscopic diagnosis of clinical leukoplakic lesions can range from hyperkeratosis to dysplasia, carcinoma
in situ, and invasive squamous cell carcinoma
diagnosis of leukoplakia is one of exclusion – need to rule out other differentials
Typically the lesions are poorly demarcated and have a corrugated hairy aspect.
 11-16% of the lesions are dysplastic
 3-6% will degenerate into carcinoma
Histological features
 Hyperkeratosis; Dysplasia (if present indicates increased malignant potential)
 Features suggestive of malignancy
1. Nuclear hyperchromatism
2. Loss of polarity
3. Increased number of mitotic figures
4. Nuclear pleomorphism
5. Altered nuclear-to-cytoplasmic ratio
6. Deep cell keratinization
7. Loss of differentiation
8. Loss of intercellular adherence
Differential Dx
1. Lichen planus
2. trauma – traumatic ulcerating granuloma with stromal eosinophilia (TUGSE), frictional keratosis in
edentulous patients, chemical burns
3. Syphilitic mucosal patches
4. Candidiasis
5. Lupus erythematosis
Variants
1. Homogenous (87% of leukoplakias) - uniform, flat, thin appearance and having a smooth, wrinkled or
corrugated surface with a consistent texture throughout. Low premalignant potential
2. Non Homogenous leukoplakia (speckled/verrucous leukoplakia)
a) consists of white flecks or fine nodules on an atrophic erythematous base
b) combination of or a transition between leukoplakia and erythroplasia,
c) higher malignant potential
3. Erythroplakia
a) Reddened areas of oral mucosa
b) Associated with in situ or invasive lesions in 50-65% of cases
High Risk Features
1. The verrucous and erythroplakia types are considered high risk.
2. Erosion or ulceration within the lesion is highly suggestive of malignancy.
3. The presence of a nodule indicates malignant potential.
4. A lesion that is hard in its periphery is predictive of malignant change.
5. Location of a leukoplakic lesion on nonkeratinized mucosa at high-risk sites for developing oral
cancer, such as the floor of the mouth, the lateral and ventral tongue, and the soft palate complex,
increases the likelihood of malignant transformation
Treatment
1. Obtain biopsy
2. Frequent clinical observation
3. surgical treatment is recommended for persistent lesions or those located at high risk sites
4. CO2 laser Rx  3 yr local control rate of 97%.
5. Photodynamic therapy
6. Excisional surgery
7. Retinoids
 Topical not effective
 Accutane (oral 13-cis-retinoic acid), 1-2mg/kg will give a complete or partial response in 2/3rd of
patients but lesions will relapse and recur once therapy is stopped.
CLINICAL EVALUATION OF H&N CANCER
History - Only 15% have previous leukoplakia.
1. Painless ulceration the most common Sx.
2. Vague soreness.
3. Pain referred to the ear from posterior oral lesions
(via the n. of Jacobson [IX], or via the n. of Arnold [X])
4. Painful or difficult swallowing (pharyngeal lesions)
5. Hoarseness and haemoptysis (laryngeal Ca)
6. Mass in the neck (advanced disease already)
7. Nasal obstr, epistaxis, pain and swelling of the cheeks (nasal and paranasal)
8. Dental Sx
9. Orbital Sx
10. LOA, LOW
Examination
 Direct visualisation of the mouth (all structures)
 Palpation of all structures of the mouth
 Laryngoscopy
 Intranasal examination
 Palpation of the neck for nodes
 Endoscopic examination of nasopharynx, hypopharynx, larynx, etc.
Aims are
i. to detect the primary lesion
ii. look for local extension, nodal, Perineural spread
iii. to allow biopsy
iv. to search for secondary synchronous lesions
INVESTIGATIONS
1. Biopsy
All suspicious lesions must be biopsied to allow Dx.
Biopsy is simple and can be done with little or no anaesthesia.
a) Scrapings can be done for cytology and may be all that is required.
b) Brushings (for cytology) may be useful. For cytological assessment one needs a well trained
histopathologist as interpretation may be difficult.
c) Biopsy forceps may be used to obtain a small piece of a large lesion.
d) Excision biopsy is only for v. small lesions and one must be careful then to excise the lesion completely
with adequate margins.
e) FNAB is accurate (SRPS: 96-100%; McC: 90%), simple, cost effective and associated with minimal Cx.
A negative result on FNAB does not rule out Ca, but merely serves as a guide to further workup.
f) U/S or CT guided FNAB may aid Dx and  sensitivity and positive and negative predictive values.
2. CT

CT may be useful for the few tumours that may be located under an intact mucosa and may give a better
guide than physical examination as to the extent of the disease.

CT is best reserved for patients whose disease is confined to a particular organ system or where deep
seated aspiration cytology is required.

CT may also be useful in assessing recurrence after surgery or radiation.

CT signs of nodal mets are:
a) extracapsular nodal spread or extension, enhancement of the nodal capsule or the presence of a poorly
defined margin around the node;
b) jugulodigastric or submandibular node > 15mm or other cervical node >10mm;
c) spherically shaped nodes;
d) groups of >3 nodes which are contiguous and confluent and each having a diam >8mm;
e) central necrosis (radiolucency) – most accurate
3. Other investigations
a) CXR, panorex and LFT’s are routine.
b) MRI

Bony invasion or tumor proximity to bone better on CT

Soft tissue and nerve infiltration better on MRI

reveals tumor necrosis and extracapsular spread with less precision than CT scan, but MRI is better for
assessing enlarged LNs that are not necessarily metastatic.
c) U/S - highest sensitivity (84%)
d) Positron emission tomography

highest specificity (82%)

In recent studies, PET has shown positive findings for lymph node metastasis when CT scan and MRI
findings were negative.

the dual use of the PET and CT scanners produces fused PET and CT scan images, which can further
enhance the results of the PET scan.
e) Triple endoscopy:
 Not cost effective in asymptomatic patients.
 Patients who have dysphagia or haemoptysis should have bronchoscopy, pharyngoesophagogram or
oesophagoscopy, all of which are relatively simple and safe.
f) Mandible involvement can be assessed by X-ray, panorex, bone scan, CT. Clinical evaluation is good for
detecting mandibular involvement (better than CT or panorex).
g) Toluidine blue dye into the oral cavity will stain the nuclei of cells in areas of ulceration, but not where
there is intact normal mucosa. The dye is not specific for malignant cells, but is a non specific indicator of
ed cell turnover or aberrant cells.
STAGING (American Joint Committee on Cancer (AJCC), 2002)
 Based on clinical examination.
 Physical examination to determine the N stage of the neck is accurate in approximately 70-80% of cases
(multiple studies)
 Aim to determine the extent of the disease so as to plan therapy.
 The most important prognostic factor in the management of oral squamous cell carcinoma is the status of
the cervical lymph nodes
 presence of metastasis to cervical lymph nodes can reduce the cure rate by 50%
Primary Tumour (T) (This is for oral cavity. Varies for pharynx and larynx)
TX
Primary tumour cannot be assessed
T0
No evidence of primary tumour
Tis
Carcinoma in situ
T1
Tumour <2cm in greatest circumference
T2
2-4cm
T3
Tumour >4cm in greatest circumference
T4
Tumour invades adjacent structures (eg., cortical bone, tongue, muscle, sinus, skin)
T4a structures that can be excised (extrinsic tongue muscles, mandible cortex, skin)
T4b unresectable structures - pterygoid plates, or skull base and/or encases internal carotid artery
Regional Lymph Nodes (N) (Applicable to all tumours)
NX
Regional lymph nodes cannot be assessed
NO
No regional lymph node involvement
NI
Metastasis in a single ipsilateral LN, <3cm in greatest dimension
N2
Metastasis in LN, 3-6cm in greatest dimension
N3
N2a
Metastasis in a single ipsilateral LN, 3-6 cm in greatest dimension
N2b
Metastasis multiple ipsilateral LN’s, all <6 cm in greatest dimension
N2c
Metastasis in bilateral or contralateral LN’s, all <6 cm in greatest dimension
Metastasis in a LN >6cm in greatest dimension
Midline nodes are considered homolateral nodes.
Distant Metastases (M)
MX
Presence of distant mets cannot be assessed
M0
No distant mets
M1
Distant mets
Stage Grouping
Stage 0
Tis
N0
M0
Stage I
T1
N0
M0
Stage II
T2
N0
M0
Stage III
T3
N0
M0
T1-3
N1
M0
<T4b N2
M0
Stage IV
T4a
Stage IVb
Any T N3
T4b
Stage IVc
N0
N0-2 M0
M0
any N M0
Any T Any N M1
T1
T2
Stage I
Stage II
N1
T3
T4a
Stage III
N2
Stage IVa
N3
Stage IVb
M+
Stage IVc
Survival
T4b
STAGE I
>75% 5YSR
STAGE II
50-75% 5YSR
STAGE III
25-50% 5YSR
STAGE IV
0-25% 5YSR
PROGNOSTIC FACTORS
The following factors are associated with a poor prognosis:
Tumour
1. Tumour thickness > 4 or 6 mm depending on site
2. Tumour grade / differentiation (differentiation not a good prognostic factor)

DNA ploidy is a more accurate prognostic factor
3. Tumor size (T staging)
4. Tumour attached to Carotid artery
5. Intravascular malignant cells
6. intralymphatic tumor emboli
7. Perineural involvement by tumour (defined as tumor invasion of the perineural sheath or epineurium)

perineural invasion has been associated with decreased survival and with increased local
recurrence necessitating more aggressive therapy.
Nodes
1. Level of positive LN – lower levels worse prognosis
2. Extracapsular spread
3. Vascular or neural invasion
4. Size
5. Bilateral do worse than ipsilateral
Indications for adjuvant radiotherapy to the neck:
1. multiple positive lymph nodes
2. extracapsular spread of disease
3. perineural invasion
The N0 Neck

Remains controversial for oral cancers

30-40% of oral carcinomas have occult metastases to the cervical lymph nodes


6-8% are micro metastasis (<6mm)
Options:
1. Observation with therapeutic neck dissection once regional metastases become apparent
2. Elective neck irradiation
3. Elective neck dissection
Observation vs Treatment

Indications for treatment
1. risk of neck disease >20%
2. primary site
3. histology of tumor (high risk tumor biology)

perineural, lymphovascular invasion

cyclin D1 and p16 molecular marker
4. young patients with no risk factors

Weiss 1994 - observation is the preferred option when the probability of occult metastasis is less than
20% and elective neck treatment (irradiation or dissection) is preferred if the probability of occult
metastasis is greater than 20%.
o In SCC of the oral cavity the sites with a less than 20% occult metastatic rate to the neck are
1. T1/T2 lip carcinomas
2. T1/T2 oral tongue carcinomas that are less than 4 mm thick
3. T1/T2 floor of mouth cancers less than or equal to 1.5 mm thick.

Advantage of observation only
1. Less morbidity (60-70% unnecessary neck dissections)
2. ELND not shown conclusively to affect overall survival

Argument for neck treatment
1. Prognostication
2. Can be used as a staging procedure – more aggressive treatment if adverse factors (excapsular
spread) found
3. Tumor recurrence with observation tends to be higher stage, and higher risk of metastasis
Surgery vs Radiotherapy

In the N0 neck, neck recurrence following DXT is 5% - similar to ELND

Often radiotherapy to neck chosen if primary site is treated with DXT

Argument for surgery
o Staging may be done
o Due to risk of metachronous cancer, may exhaust future DXT options

the literature provides no clear-cut recommendation for using ENI or END to treat N0 necks. The most
important factors in guiding this decision should be the patient's informed decision, physician and
institution experience, risk of second primary occurrence in the future, and the modality chosen to treat
the primary cancer.
Type of Neck Dissection

lymph nodes at highest risk of occult metastases from oral cavity cancers are those at levels I, II, and III.

The metastatic rates to these sites are 58% (level I), 51% (level II), 26% (level III), 9% (level IV), and
2% (level V).

Several studies have shown that there is no statistically significant difference in locoregional recurrence
between a selective neck dissection and a radical neck dissection

Byers (MD Anderson) noted a skip metastasis rate of 15% to level IV in squamous cell carcinoma
of the oral tongue and advocated that dissection of level IV should be included in a selective neck
dissection.

More recently it has been demonstrated that level IV need be dissected only if there are suspicious
nodes in level II or III
Combined modality

Consider use of postoperative radiation therapy when there are perineural, intravascular, and
intralymphatic tumor spread, positive microscopic margins, more than two histologically positive lymph
nodes, extracapsular spread, and DNA nondiploid tumors.
Contralateral neck

treatment of the contralateral nodes if the primary oral cavity cancer is
1. midline
2. bilateral
3. along the tip of the tongue
4. approaches or crosses the midline.
Future directions

proton magnetic resonance spectroscopy

sentinel lymph node biopsy
CANCER BY SPECIFIC SITES
1. ORAL CAVITY
ANATOMY

Boundaries
o lip vermillion junction
o junction hard and soft palate above
o anterior tonsillar pillar
o line of circumvallate papillae below
SITES
1. Lip
commonest (40%)
2. Anterior 2/3 tongue.
36%
3. Floor of mouth (FOM)
35%
4. lower alveolar ridge
16%
5. Buccal mucosa
10%
6. Hard palate
3%
7. upper alveolar ridge
8. Retromolar trigone

main routes of lymph node drainage are into the first station nodes (i.e., buccinator, jugulodigastric,
submandibular, and submental).

second station nodes include the parotid, jugular, and the upper and lower posterior cervical nodes.

Sites close to the midline often drain bilaterally.
LIP

The most common site for H&N Ca is the lower lip (up to 40% in some series).

BCC predominates in upper lip

SCC of lower lip - 7.7 per 100 000 people in Australia

Associations: smoking, leukoplakia and outdoors activities.

Synchronous SCC in 5%
Lymphatic drainage

Lymphatic drainage from the upper lip is unilateral except for the midline. The lymphatics coalesce to
form 5 primary trunks that mainly lead to the ipsilateral submandibular nodes, with some drainage also
going to the periparotid lymph nodes. Occasionally, some drainage may be available to the ipsilateral
submental lymph nodes.

The lower lip lymphatics also coalesce to form 5 primary trunks that lead to bilateral submental nodes
from the central lip and unilateral submandibular lymph nodes from the lateral lip.

The submental, submandibular, and parotid lymph nodes are the first echelon nodes for the lips.
Submental nodes secondarily drain to ipsilateral submandibular nodes, and both submandibular and
parotid nodes secondarily drain to ipsilateral jugulodigastric lymph nodes
Treatment


impalpable chronically unstable actinically damaged vermilion

ultraviolet lipstick

if fails, then vermillionectomy
Many studies show radiotherapy and surgery to be equivalent treatments for primary T1-2 tumors in local
disease control for the overall group and for stage-matched lesions.; and overall survival

RT probably related to higher risk of metachronous lip SCC(11 vs 20%)

TI lesions - surgery advocated. If the commissure is involved, DXRT may allow preservation.

T2 to T4 lesions - surgery and post-op RT (better 5YSR).

Surgical margins:

Brodland and Zitelli found that in excised cutaneous SCC < 2 cm in diameter (including lip SCC) a
4 mm margin was required to obtain clear margins 95% of the time. Tumours >2 cm required 6 mm
margins to achieve 95% clearance


With frozen section control, closer margins may be acceptable
Radiotherapy alone recommended in selected cases
1. older patients (> 60 years) for whom surgery was considered less advisable due to, for example, fear
of surgery or hospital admission
2. poor health
3. anticoagulation,
4. where surgery would result in a poor functional outcome.

Consider combined resection and vermilionectomy surgery - incidence of 60% synchronous dysplastic or
actinic changes, 5% synchronouos lip carcinoma and 15% metachronous lip carcinoma

N0 LN dissection (LND) is not indicated in most instances – nodal recurrence rate reported at 5-10%

Node +’ve necks require ipsilateral LND.

If the lesion crosses the midline, a contralateral suprahyoid LND should be done.
Prognosis

Recurrence rate 5-30%

95% of recurrences occurs within 4years

Risk of recurrence related to
1. clinical stage - Lesion size is the most important determinant of tumour behaviour.
2. age (younger do worse)
3. tumor grade

5YSR for all stages: 70-90%.

5YSR for T1 and T2, N0 lesions is 90% - majority of patients present at T1

Of those that develop nodal mets, 58% eventually develop uncontrolled neck disease.

low incidence of nodal metastases at presentation (2% clinically positive lymphadenopathy at Peter
McCallum – ANZJS 2000) compared to an incidence of 10–15% reported elsewhere (USA)

metachronous lesions continues to develop 10 years after presentation, indicating need for prolonged
surveillance in these high-risk patients. This requirement may be obviated by the use of a combined
resection and vermilionectomy procedure, which was shown to provide the most effective long-term
control
TONGUE (anterior 2/3rd)
Clinically
 Tumour typically occurs on lateral tongue.
 Associations: tobacco, alcohol, poor oral hygiene and leukoplakia.
 Examine for tongue fixation (poke tongue out)
 Most patients present in stage 1 or 2.
 Peak incidence in the elderly.
 Clinical assessment of lymph node status preoperatively is unhelpful, with studies reporting a high falsenegative rate (25% false negative rate)
Lymphatics spread
 Principal sentinel lymph nodes (SLNs) for anterior part of tongue were submental lymph nodes,
submandibular lymph nodes and juguloomohyoid lymph nodes – mostly to level II,III
 For lateral part and middle part of tongue were submandibular lymph nodes, jugulodigastric lymph nodes
and thyroid lymph nodes,
 for root part of tongue - jugulodigastric lymph nodes.
 Drains to both sides but frequency of stained SLNs at homolateral neck was more than that at contralateral
neck.
 Only tongue tumors demonstrate skip nodal spread (ie involving lower neck nodes without upper nodes) level IV nodes should be included in staging and therapeutic neck dissections in tongue cancer according
to some
 The probability of nodal mets is based on the size of the primary:
T1 - 15%
T2 - 30%
T3 - 50%
T4 - 75%
 Tumour thickness is a stronger predictor for metastatic spread to neck nodes (measured by MRI or
intraoral US)
 N+ in 51% (>5mm thickness) and 8% (<5mm) – Veness ANZJS 2005 Westmead
 50%(>3mm) and 8% (<3mm) – Yuen Head/Neck 2002)
 38%(>4mm) and 3%(<4mm) – Kurokawa
 47%(>2mm) and 12%(<2mm) - Spiro
 25% of untreated N0 necks subsequently develop mets in the neck. Salvage surgery after nodal recurrence
is very poor (<25%)
Treatment of the Primary Tumour
 Stage 1 or 2 - surgery or irradiation. (External beam (60-65 Gy) or brachytherapy).
 Primary radiotherapy often preferred in posterior 1/3rd to preserve function
 Surgical excision is with a 1-2 cm margin. The best chance for cure is at the first operation.
 Surgical salvage of XRT failures is rarely successful.
 Stage 3 and 4 tumours should receive post-op DXRT to local site
 Large defects require flap reconstruction to preserve mobility and function.
 Local control rates after surgery:
 T1 – 75-96%
 T2 – 57-92%
 T3 – 45-73%
 T4 – 13-35%
 Overall, failure at the primary site occurs in 31% to 58%, mostly T3-4 lesions
Treatment of the Neck
 T1, N0
 < 15% chance of neck nodes being +ve, no treatment required (McC).
 Shah, on the other hand, states that with anterior tongue T1, N0 tumours, there is a 30% chance of +ve
nodes and he therefore advocates a ND.
 Best approach
 Excision only if good tumor characteristics
 ELND if poorly differentiated, thickness > 4 mm (Fakih, 1989), perineural/vascular/lymphatic
invasion
 T2-4, N0  >30% chance of neck nodes being +ve. Treatment can be either by ND or DXRT and is
determined by individual case: the patient, the treatment team. Generally a ND is advocated if patient fit
enough for surgery. It allows histological Dx of the nodes and reserves DXRT for future.
Which ND? Controversial (elective modified radical classical versus supraomohyoid neck dissection)

Shah advocates SOHND

No difference in recurrence and survival rates - Brazilian Head and Neck Cancer Study Group
Am J Surg 1998

Others (ie MD Anderson) levels I-V due to skin lesions (15% incidence of skip lesions), but with
preservation of non nodal structures

 Others recommend observation only – most studies indicate ELND may reduce regional recurrence and
disease free survival but have no impact on overall survival
 Midline lesions  Bilateral SOHND or FND.
 If +ve nodes are found, post op DXRT is indicated - XRT with neck dissection provides superior regional
disease control than single-modality treatment alone.
 If there is peri-neural involvement by the primary tumour post op DXRT to the primary and ipsilateral
neck is recommended.
 Post-op irradiation does not prevent recovery of tongue function.
 Generally DXRT is given to neck, if the primary is treated by DXRT only.
 N+ necks generally treated with MRND although trials are in progress using SOHND.
In patients < 40 years of age:
 The tumour is much more aggressive. Many die of their disease (51%).
 Nodal mets are more common. The recurrence rate is ed (68%).
 One study quoted the 3YSR as being only 17%.
 Radical surgery, irradiation and adjuvant immunotherapy is indicated.
Overall Survival of patients with Ca of Tongue
Nodes -ve

71-85% 5YSR
Nodes +ve

26-35% 5YSR
 If tumour margins are adequate, local recurrence is rare.
 If recurrence occurs, this is rarely controlled (30 to 38%).
 Speech and swallowing generally return to normal after surgery and/or DXRT.
FLOOR OF MOUTH

Third commonest site for Ca of the oral cavity.

Most lesions are anterior and involve other structures.

Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a
tumor as T4

Bimanually palpate for fixation to mandible, submandibular involvement, check mental nerve
Sx
a) Mass or ulcer (70%)
b) Pain (26%)
c) Earache (7%)
Spread
 Via
a) submandibular duct;
b) the lingual nerve;
c) branches of the lingual vessels.
 Lesions may spread via the submucosa to the opposite side and bilateral lesions are therefore common.
 FOM lesions have a higher incidence of distant mets (50%) than local recurrence (11%). (Compare with
tongue lesions: 21% and 38%).
 Anterior FOM lesions spread to the submental, submandibular and then to upper and middle deep cervical
nodes. Lymphatic spread is common (T1  20%).
 Direct invasion of FOM muscles is also common (75% at initial presentation).
 Posterior to the mylohyoid there is direct communication between the mouth and submandibular areas and
posterior lesions therefore require removal of the submandibular tissue.
 Posterior lesions drain to the jugulodigastric and jugulocarotid group of nodes.
Priorities
1. to allow freedom of the tongue, especially on the anterior floor (avoid tethering of tongue)
2. to avoid redundancy of the flap, which compromises proper hygiene as the folds trap food particles,
3. use thin flaps, which drape gently over the alveolus (native or reconstructed mandible) and floor of
the mouth and permit denture wearing
Treatment
Surgery has a better cure rate (25 to 65%) than DXRT which is associated with:
a) High recurrence rates,
b) Debilitating morbidity
c) Serious long term sequelae,

Early stage disease cure rate ~ 80%.

Advanced disease best treated with post-op DXRT.

ELND recommended for T2 lesions or greater (or T1 with high risk features) – risk of cervical mets in
N0 FOM is 2% if <1.5mm thick, 33% 1.5-3.6mm and 60%>3.6mm (Am J Surg 1986)
Treatment failure and poor prognosis associated with:
a) tumour thickness > 7mm,
b) perineural invasion,
c) intralymphatic tumour emboli,
d) higher grade and stage.
4. INFERIOR ALVEOLAR RIDGE (including retromolar trigone)
 ~ 16% of oral cancers.
 2/3 of pts have localised tumour (N0).
 Assess for tooth loosening, mental nerve
 At the time of Dx, 30-50% are likely to have positive neck nodes.
 10-15% of patients found to have a 2nd primary.
 Distant mets develop in 15-20%.
Treatment of the Primary
The preferred treatment of stage I and II disease is surgical to avoid irradiating the bone.
Mandibular involvement and selective application of marginal mandibulectomy:

The most significant indicator of prognosis is invasion into the mandible.
Bone not involved
Bone involved
T1
83% 2YSR
66% 2YSR
T3 and T4
67% 2YSR
20% 2YSR

Direct spread of the tumour can occur to the periosteum of the mandible and the tumour can enter the
bone through the occlusal ridge. Thereafter perineural spread may occur along the inferior alveolar
nerve. In the irradiated case the tumour may enter the bone anywhere (ie, through any cortical defect).
Some patients have demonstrated discontinuous periosteal involvement (which can result in recurrence).

Totsuka et al recommend marginal mandibular resection only if the erosive bone defect is in the
superficial alveolar bone and does not extend beyond the inferior alveolar canal. (cure rates > 82%).

Stage III disease, in selected cases, therefore can be treated by excision with marginal mandibulectomy
and post-op DXRT.

Stage IV disease with bony invasion, needs to be treated with segmental or hemimandibulectomy.

When there is no evidence of tumour involvement of the mandible it should be preserved.

Marginal mandibulectomy is reserved for cases where there is periosteal reaction or evidence of tumour
at the periosteum.
Neck Dissection

Nodal spread is usually to JD, submaxillary and midjugular chain.

Probability of nodal spread according to size of primary:
T1  10-15%
T2  40%
T3  50%
T4  70%

Staging supraomohyoid ND recommended for patients with N0 necks and high T stage.

RND or MDND for N+ necks.
Post-op RT
a) Pts with occult cervical mets
b) Pts whose surgical margins were inadequate
c) Pts whose risk of treatment failure is considered high (Stages III and IV).
Predictive of low survival
a) Advanced clinical stage
b) Prior dental extraction
c) Bone invasion
d) Involvement of surgical margins
Survival
Overall 5YSR is 50-65% with a significantly poorer prognosis in advanced disease.
5. BUCCAL MUCOSA

5% of H&N Ca and 10% of SCC of the oral cavity.

Mostly are posterior and usually occur on or just below the occlusal plane.

Mandible involved more often than the maxilla.

Strong association with leukoplakia, alcohol and snuff.

With advanced disease patients can get trismus.

Lymphatic drainage is to:
a) Submaxillary triangle,
b) Parotid and periglandular nodes,
c) JD and the deep jugular, and,
d) Submental nodes.

Most patients are stage 1 or 2 at presentation.

40-50% of patients have LN mets at the time of presentation.

Frequency of +ve nodes according to size of primary
T1-2
30-35%
T3
50-60%

Distant mets present in 2% at presentation, but subsequently occur in 11% during FU.

14-29% subsequently Dxed as having a 2nd primary.
Treatment
 Surgical resection and reconstruction with local flaps (small lesions) or distant flaps for larger ones.
 Ideally, thin flaps required.
 Stage III and IV usually require lining and skin.
 Bone excision and reconstruction may also be required in these advanced cases.
 Post-op irradiation to improve local control and survival.
Survival

Tumour thickness
5YSR
<6mm
>85%
>6mm
40%
6. SUPERIOR ALVEOLAR RIDGE AND PALATE

Relatively rare.

Lymphatic drainage is to submaxillary and JD nodes.

Posterior lesions frequently drain to retropharyngeal nodes.

1/3 have nodes at presentation.

10-15% develop distant mets.
Treatment

Stage I and II lesions are treated by W.L.E or DXRT (60 to 80 Gy) or brachytherapy

If N+, a RND or MRND and DXRT is indicated.

Mets to the neck are uncommon.

If the primary site does not need post-op RT, one can observe the neck.
Survival
Difficult to determine because an uncommon tumour. (20-55% 5YSR).
B. OROPHARYNX
 Boundaries:
 Junction of hard and soft (curcumvallate papilla tongue ) anteriorly to level of hyoid bone
 Includes:
1. Tonsillar fossa
(43%)
2. Soft palate and uvula
(26%)
3. Base of tongue
(20%)
4. Pharyngeal walls
(11%)
 potential fascial spaces around oropharynx for tumor spread once muscular layers of tongue intrinsics and
constrictors breached
1. retropharyngeal space – lies posteriorly
2. parapharyngeal space lateral to the pharyngeal constrictors that forms an inverted pyramid with its
base at the skull and its apex at the greater cornu of the hyoid bone.
a. contains branches of the trigeminal nerve, pterygoid muscles, and the internal maxillary
artery.
 Functionally, the oropharynx is critical for
1. proper speech production (phonation)
a. prevents hypernasal speech
2. respiration
3. deglutition
a. soft palate closure prevents regurgitation
b. base of tongue acts in concert by propelling the food bolus into the hypopharynx
4. airway protection
5. taste sensation
6. immunologic surveillance

surgical resection of oropharyngeal cancers may result in poor speech production, dysphagia, or
aspiration.
Clinical

most common symptom is throat discomfort

Other complaints include odynophagia, a globus sensation, and otalgia.

With invasion of deep musculature, trismus, dysphagia, and dysarthria may develop.

Additional late symptoms include bleeding, aspiration, airway obstruction, and weight loss.
Epidemiology
 Ca of faucal arch- 99% have a smoking Hx.
 Most patients <35 yrs are women.
Prognosis
 Generally SCC’s are less differentiated, nodal mets more common and survival is worse c.f. oral SCC’s.
 Tumour extension to base of tongue and across the midline, further worsen survival.
 Generally the more posterior, the worse the survival.
 For early stage disease, local surgery or RT controls the disease in 75%.
 The other 25% have regional recurrence, only ½ of whom are salvaged by secondary treatment.
 Surgery, radiation therapy, and chemoradiation therapy, individually or in combination, are the mainstays
of treatment for squamous cell carcinoma of the oropharynx.
Arguments against surgery
1. even early-stage carcinomas are at risk for regional lymph node metastases
2. Traditional neck dissections often fail to address retropharyngeal and parapharyngeal lymphatics,
which are at risk in patients with oropharyngeal carcinoma.
3. high risk of bilateral neck disease

Because of these issues and the morbidity of surgical resection of the oropharynx, there has been an
overall trend toward primary therapy with radiation or chemoradiation therapy, especially for advanced
disease.

Single-modality therapy with radiation or surgery can achieve similar locoregional control for early and
intermediate cancers, with radiotherapy generally yielding better functional outcomes

However many patients undergoing primary surgical resection require postoperative radiation therapy
because of the presence of positive nodes, extracapsular spread, or perineural invasion.

Several studies have reported improved locoregional and overall disease-free survival in patients
receiving postoperative radiation therapy versus surgical treatment alone. Many institutions therefore
recommend radiation therapy for early-stage disease and chemoradiation therapy for intermediate- and
advanced-stage disease
Surgery

In general, surgical treatment of oropharyngeal carcinomas is typically reserved for patients who have
failed primary radiation or chemoradiation therapy and for those who for any reason are not candidates
for such therapy.

The key factor in any approach is adequate exposure.

Generally, all approaches are accompanied by a neck dissection.
Approaches
1. transoral - preferred for excising smaller lesions of the soft palate, posterior pharyngeal wall, tonsil and
anterior pillar, and uvula. Transoral laser recently described
2. Transoral/Transcervical
3. Lingual-mandibular release (tongue drop)
1. Base of tongue lesions
2. Incision through floor of mouth from tonsillar pillar to pillar
3. Tongue and floor of mouth released and pulled below mandible into neck
4. Risk damage to lingual arteries and nerve and CN 12
4. Transpharyngeal
1. suprahyoid approach

most appropriate for small neoplasms of the midline base of tongue.

A cervical incision is required, followed by entering the pharynx above the hyoid bone into
the vallecula
2. a lateral pharyngotomy approach.

pharynx is entered between the hypoglossal and superior laryngeal nerves.
5. Transmandibular


lip-splitting or a visor flap incision if mandibulectomy required
Reconstruction
o Aim: restore functional speech and swallowing while providing an adequate airway.
o Direct closure
o skin graft - limited to lesions along the posterior and lateral pharyngeal wall where a bolster can
be placed.
o
pedicled flap – pec major
o Free flaps – radial forearm, lateral arm flap
1. TONSILS
 Commonest site in the oropharynx (75%).
 Because the area is rich in lymphatics, lymphatic spread is frequent at the time of Dx (70-90%).
 Commonest sites of lymphatic involvement are submandibular, JD, mid and lower jugular nodes.
 Bilateral nodal involvement in 11%.
 Often involve adjacent structures (T3, 60%; T4, 90%): most often presents with involvement of the
anterior tonsillar pillar. Also frequently spread anteriorly or medially to involve the retromolar trigone,
buccal, and tongue base mucosa. Extension posteriorly onto the pharyngeal wall occurs much less
commonly
 Because these lesions infiltrate deeply, the lingual nerve, inferior alveolar nerve, glossopharyngeal nerve,
and mandible may become involved just deep to the anterior tonsillar pillar. Eventual involvement of the
pterygoid musculature and parapharyngeal space will cause significant trismus.
 2nd primary in 15-35%.
 70% present with lymph node mets
 Metastases to contralateral lymph nodes occur in up to 22% of tonsillar fossa lesions and in 6% of lesions
of the anterior tonsillar pillar
 Distant mets in up to 20%.
Treatment
 Early stage lesions equally well treated by surgery as by irradiation.
 Tonsillar fossa lesions (T1 or T2) are best treated by DXRT.
 Tonsillar pillar lesions are best treated by surgery alone or combined surgery and DXRT.
 Patients treated with surgery usually get recurrences in the neck.
 Patients treated with DXRT usually get recurrences at the primary site.
 Stage III and IV lesions require W.L.E and post-op DXRT but despite flap coverage frequently require a
palatal obturator to maintain some VP closure.
The neck
 Because of the high frequency of LN spread, the neck should be treated as well.
5YSR
Stage I:
63%
Stage IV:
21%
2. SOFT PALATE
 2nd commonest tumour of the oropharynx (26%)
 most common chief complaint is odynophagia.
 Usually Dxed early.
 30-40% have LN at presentation.
 Frequency of +ve nodes varies according to T stage of primary:
T1
8%
T2
37%
T3
65%
T4
67%
 Usually drain to JD and midjugular nodes. Occasionally may go to retropharyngeal nodes, posterior
triangle and lower jugular nodes.
 Bilateral LNs in 16%.
 Second primary on follow up in 24-42%.
Treatment
 DXRT is less debilitating and is the treatment of choice even for small lesions.
 Initial control:
(Stage) T1
T2
T3
After DXRT alone:
83%
67%
63%
After DXRT and surgery:
92%
80%
75%
 In clinically -ve necks, DXRT achieved control in 96% (Horton).
 In +ve necks (N1) DXRT achieved control in 86%.
Survival
 Overall 5YSR: 30%.
 Generally has a poor survival compared to other tumours of the oropharynx.
3. BASE OF TONGUE (Posterior 1/3)
 Most common symptom – sore throat
 Often present with advanced disease.
 75% have +ve nodes at presentation.
 20% have bilateral nodes at the time of presentation.
 25% have spread to larynx at presentation.
 50% cross the midline at presentation.
 Frequency of +ve nodes varies with T stage:
T1-2
70%
T3
75%
T4
85%
 LN drainage is to JD and midjugular nodes.
 Second primaries in 22%.
 Overall survival 20%
Treatment
 Wide local resection and flap reconstruction. Rarely achieve primary closure. ND in all.
 Early exophytic lesions should be treated by DXRT +/- ChemoRx.
 Iridium-192 implants are effective adjuncts.
 Total glossectomy can give excellent functional results and  survival dramatically.
Survival
 5YSR:
Stage I:
42 to 63%
Stage IV:
10 to 21%
 Often the larynx can be spared and 80% will speak intelligibly afterwards.
4. PHARYNGEAL WALL
 Uncommon primary tumour although often involved in secondary extensions from other tumours.
 often extend either superiorly to the nasopharynx or inferiorly to the hypopharynx.
 Usually advanced at the time of Dx.
 LN drainage: JD and midjugular nodes
 60% of patients have +ve nodes at the time of Dx. Bilateral LN in 15-20% of cases.
 The bigger the T stage, the greater the chance of nodes:
T1
25%
T2
30%
T3
67%
T4
76%
 Combined therapy best.
 Larger lesions require mandibular split.
C. NASOPHARYNX
 Unusual tumour.
 Associations:
1. environmental factors (nickel, chromium, wood workers)
2. viral factors (EBV)
3. genetic predisposition (Chinese)
 Clinical
 Trotter triad consists of decreased hearing, mandibular pain, and impaired soft palate mobility
 Cavernous sinus invasion occurs because the tumor tracks through the foramen lacerum, which often
leads to multiple CN deficits.
 order of loss is CNs VI, III, V1, V2, and IV
 Classification into 3 different types (WHO)
1) SCC (5%)
2) nonkeratinizing carcinoma – large cell carcinoma
3) Undifferentiated (most common 70-90%)
 T stage based on local extent of the tumour rather than absolute size.
T1
1 site or +ve biopsy with no tumour visible.
T2
2 sites (postero-superior and lateral walls)
T3
Spread to nasal cavity or oropharynx
T4
Spread to skull or cranial nerve
 Boundaries
Superiorly:
base of the skull
Posteriorly:
arch of the atlas
Laterally:
mucosa over palatine arches and carotids
 Commonest site: Lateral wall in the fossa of Rosenmuller (posterior to Eustachian canal)
 Lymphatic drainage: node of Rouviere is the most commonly involved lymph node. It usually lies below
the base of the skull near the level of the atlas and may overlay the internal carotid artery. Upper cervical
lymph node chain encases the internal jugular vein and receives lymph from the node of Rouviere.
 60% have LNs at the time of Dx. Bilateral LNs in 50% during the course of the disease.
Management
 NPCs with no distant metastasis are typically treated with nonsurgical means
 High-dose radiation therapy is the primary treatment, both for the primary tumor site and the neck
 results of a phase III randomized controlled trial reported in 1998 established that concurrent
chemoirradiation followed by adjuvant chemotherapy is the standard of care for NPC
 Surgery is limited to neck recurrence following DXRT.
 5YSR: 35-50%. (Worse for type 1, better for types 2 and 3).
 Complications related to radiotherapy
1. xerostomia – poor dental hygiene
2. trismus (5-10%) - result of fibrosis and contraction of the pterygoid muscles or fibrosis of the
temporomandibular join
3. Brain necrosis (2%)
4. radiation-induced retinopathy and injury to the optic nerve can occur, causing blindness
5. CN entrapment (especially for the last 4 CNs) due to soft tissue fibrosis - 1-6%.
D. HYPOPHARYNX
 From the hyoid to the lower border of the cricoid. Three areas
1. the piriform recess
60-80%
2. lower posterior pharyngeal wall.
15-35%
3. the posterior surface of the larynx (postcricoid area)
5-15%
 Usually Dx late. Patients usually present with a fixed mass in the neck.
Clinically (in order of frequency)
1. Dysphagia
2. Throat pain
3. Neck mass
4. Hoarseness
5. Haemoptysis
6. Otalgia – Arnold’s nerve
 2/3’s to 80% have +ve nodes at presentation  JD and midjugular.
 Bilateral nodal involvement is common.
 T1-2  60-70% have +ve nodes.
 T3-4  75-80% have +ve nodes.
 Most tumours are poorly differentiated.
 Skip lesions are notoriously common.
 Endoscopy, Ba swallow, CT.
Treatment
 Combined therapy associated with the best prognosis.
 total laryngectomy with partial or total pharyngectomy plus node dissection and postop DXRT to primary
and neck remains most common treatment
 Para~ and retropharyngeal nodes (node of Rouviere) must be sought and removed.
 Reconstruction by gastric pull up or free jejunal flap.
Survival
 5YSR: 30-55%.
 Recurrence always fatal.
E. LARYNX
 Second commonest site of SCC of the H&N (25% of all malignancies of the H&N).
 3 regions: supraglottis (30-50%), glottis (60%), subglottis (1-4%).
 Supraglottic tumours have a poorer prognosis because of a predilection for lymphatic spread.
 Present usually with a change in the character or quality of the voice, sore throat, otalgia, dysphagia.
 Persistence of these Sx for more than a few weeks demands laryngoscopy.
T1
Confined to site of origin with normal mobility.
T2
Involves adjacent site without fixation
T3
Fixation of tumour
T4
Extension beyond the larynx
 Rarely spread to the cervical nodes:
T1
5%
T2
8%
T3
15%
 Only T4 lesions require elective treatment of the neck.
 Midjugular, pretracheal (Delphian), paratracheal LNs.
 Supraglottic stage I and II best treated with irradiation (including the neck).
 Supraglottic stage III and IV best treated with laryngectomy.
 Glottic stage I and II tumours: DXRT, laser, surgery.
 Glottic stage III and IV tumours  laryngectomy + DXRT to primary and neck.
F. PARANASAL SINUS
 Rare (3% of H&N Ca).