Adenoid Cystic Carcinoma

Minor salivary glands lining the sinonasal tract may give rise to malignancies of salivary origin. Adenoid cystic carcinomas account for 5 to 15 percent of sinonasal malignancies and occur equally in both sexes with a peak age incidence between 40 and 60 years. Clinically, adenoid cystic carcinoma is marked by locally aggressive disease with a slow, relentless progression. Although regional lymphatic spread of adenoid cystic carcinoma is uncommon, both local recurrence and distant metastases...

Anatomy and Diagnosis

Neurofibromas are non-encapsulated, peripheral nerve sheath tumors that cause a fusiform dilatation of their nerve of origin.19 While these tumors may occur as solitary, subcutaneous or submucosal masses, they more commonly present as multiple discrete tumor nodules or with extensive nerve sheath distortion (plexiform neurofibromatosis Figure 16-17) in association with one of the two forms of neurofibromatosis (NF). Neurofibromatosis type 1 (NF-1), also known as von Recklinghausen's...

Associated Medical Conditions

As hypopharynx and cervical esophagus cancer typically occur in older patients, associated medical con ditions are often present and should be included when considering treatment options. Although patients with weight loss more than 10 percent during the 6 months before surgery are at greater risk for the occurrence of major postoperative complications, cachexia and malnutrition are not contraindications to treatment due to improvements in nutritional assessment and delivery via enteral and...

Basal Cell Carcinoma

Basal cell carcinomas (BCC) account for the vast majority of non-melanoma skin cancers (75 ) and well over 25 percent of all cancers diagnosed in the United States each year.49-51 Five clinical histopathologic subtypes of basal cell carcinoma have been described of which nodular ulcerative is most common, followed by pigmented, superficial, morphea-like, and fibroepithelioma. 51 BCC has a predilection for fair-skinned individuals but can occur in Latin American and African American patients.52...

Benign Tumors

These tumors arise from the skin appendages and can show pilosebaceous, eccrine, or apocrine differentiation. Common benign adnexal tumors include nevus sebaceous, trichoepithelioma, pilomatricoma, cylindroma, syringocystadenoma papilliferum, syringoma, and eccrine spiradenoma. Nevus sebaceous tumors are congenital hamar-tomas of the skin that probably arise from basal cells. These lesions typically involve the face and scalp regions of children, ranging in appearance from slightly raised...

Buccal Mucosa Retromolar Trigone Hard Palate

Diagram of the oral cavity and subsites. upper lip possesses two peaks forming a cupid's bow where the filtrum ascends to the columella of the nasal septum. The orbicularis oris muscle receives motor innervation from the marginal and buccal branches of the facial nerve and performs a sphincteral function to maintain oral competence and to facilitate articulation of speech. This muscle has many attachments from other muscles of facial expression that elevate and depress the lips. Of...

Case 10 Island Pedicle Flap

Island pedicle flaps with their vascular pedicles can be isolated in various locations in the head and neck area. One of the most versatile and easily available island pedicle flaps is based on the anterior branch of the superficial temporal artery and vein which provides blood supply to the forehead. This flap is elevated from the lateral aspect of the forehead. Its advantages include fairly regular and identifiable artery and vein, a long vascular pedicle, and thick forehead skin to provide...

Case 3 Excision and Fullthickness Skin Graft on the Nose

Nasal Skin Graft

This patient presented with Hutchinson's melanotic freckle (lentigo maligna) on the dorsum of the nose. The desired extent of excision is marked out with a skin marking pen and its dimensions are measured. The ideal donor site is the skin of the supraclavicu-lar region for a defect of this size. The postoperative appearance of the skin graft in this patient immediately after surgery is shown in Figure 4-6A and 6 months postoperatively in Figure 4-6B. Since sensations on this skin are absent,...

Case 6 Rhomboid Flap

This versatile geometric flap was described by Limberg, a mathematician. It can be used in many areas of the body and provides a satisfactory closure of surgical defects, particularly in patients with lax skin. The patient shown in Figure 4-10A was referred having undergone excisional biopsy of a malignant melanoma of the cheek. The scar of previous surgery was widely encompassed in the surgical incisions which were planned to provide access for superficial parotidectomy at the same operation....

Case 8 Mustarde Advancement Rotation Cheek Flap

Skin defects resulting from surgical excision of lesions involving the skin in the infraorbital region and medial part of the cheek are best suited for repair using a Mustarde flap. The major blood supply of this skin flap is from the posterior branches of the facial artery with the wide pedicle of the flap remaining inferiorly. A patient with a Hutchinson's melanotic freckle (lentigo maligna or in situ melanoma) presenting on the skin of the cheek in the right infraorbital region is shown in...

Clinical Presentation And Diagnosis

Small tumors at certain sites, such as the crypts of the tonsils, the glossotonsillar sulci and the tongue base rarely produce symptoms and are not always easy to detect. When present, the initial symptoms of oropharyngeal cancer are often vague and nonspecific, leading to a delay in diagnosis. Consequently, the overwhelming majority of patients present with locally advanced tumors. Presenting symptoms may include sore throat, foreign-body sensation in the throat, altered voice or referred pain...

Condylar Reconstruction

The condyle is sometimes resected in combination with the ramus and angle of the mandible for tumors which originate in the lateral pharynx, external skin, or parotid gland. In cases where the condyle is not involved with tumor it is preferable to transplant the proximal 2.0 to 2.5 cm of condyle back onto the reconstructed mandible using titanium plates and screws.35 An intraoperative frozen section of the Figure 19-5. A, A 49-year-old woman with a recurrent parotid tumor after receiving...

Definition of Radiation

Radiation is energy which is emitted from atoms and is transmitted through space.1 It is the capture of this energy emanating from physical reactions occurring at an atomic level and its application to cellular material which results in biologic change that forms the scientific basis of the specialty of radiation oncology. There is a broad spectrum of radiation types, however the particular one of clinical interest is known as ionizing radiation. This is defined as radiation of sufficient...

Diagnosis

What Dentascan

The diagnostic evaluation of a patient with oral carcinoma consists of the history and the physical examination, histopathologic tissue diagnosis, and imaging when indicated. The clinical history begins with the present illness and includes the duration and location of symptoms such as non-healing ulcer, mass in the oral cavity or neck, pain, bleeding, and any symptoms of cranial nerve deficits. A thorough exploration of the patient's past medical and surgical history, and the review of systems...

Diagnosis Symptoms

Mass Hard Palate

Nasal cavity and paranasal sinus malignancies often do not cause symptoms until they have expanded to a significant size or have extended through the bony confines of the sinus cavity. These tumors therefore tend to present at a more advanced stage. Symptoms may initially include nasal obstruction, epistaxis, pain, and episodes of sinusitis. Tumor expansion inferiorly towards the oral cavity may be associated with swelling of the gingiva or palate with loose teeth, while orbital invasion may...

Elective Neck Dissection

Elective treatment of cervical lymph node metastasis is generally recommended when the risk of occult disease is around 15 to 20 percent. Candela and colleagues demonstrated that the nodal groups at risk from laryngeal cancer are at levels II, III and IV.32 Level I was rarely involved in isolation and level V was never involved alone. This tends to support the removal of levels II, III and IV, the so-called jugular node dissection or lateral neck dissection, Surgical specimen from supracricoid...

Ethmoid Sinus

Lesions of the ethmoid sinuses tend to be of high grade and are associated with a significant risk for local recurrences despite negative margins. The generally preferred approach is with surgery and postoperative radiation therapy. Early lesions in the anterior ethmoid sinus can often be excised surgically. For involvement of the middle and or posterior ethmoid sinuses and for extensive disease, craniofacial resection and sometimes orbital exenteration may be necessary. Postoperative radiation...

Fibroepithelial Polyp

Also known as skin tags, fibroepithelial polyps typically develop in middle-aged persons and are of limited consequence. These lesions are usually removed for cosmetic reasons, although they may become quite large and symptomatic due to irritation or trauma. The pedunculated lesions are usually fleshy and are composed of an epithelial covering and a fibrovascular core. Occasional case reports have demonstrated the presence of coexistent carcinoma but this is rare, with one series showing only 5...

General Principles

Treatment of tumors of the oropharynx has the potential to cause significant functional deficit, and the optimal treatment plan must strike a balance between minimum functional derangement and long-term disease-free survival. Surgery or radiation therapy, alone or in combination, are currently accepted as standard treatment for oropha-ryngeal cancer. Other modalities such as chemotherapy must be considered experimental and are generally reserved for patients with advanced or recurrent disease...

Improving the Therapeutic Ratio

The use of multiple fractions over many weeks of radiation therapy is based on the principle of improving the therapeutic ratio between normal tissues and tumors (Table 21-3). The goal is to maximize the cell death of tumors and to minimize unacceptable damage to normal cells. The radiobiologic mechanisms involved with causing cell death are similar for both normal and malignant cells. It is the differential ability of ionizing radiation to sterilize tumor while avoiding excessive normal tissue...

Jo

The extra-adrenal paraganglia are neural crest-derived rests of tissue that migrate to sites in the body in close association with cranial nerves, the aorta and its branches.48 These paraganglia are composed of two predominant cell types the sustentac-ular cells and the chief cells. The sustentacular cells are modified Schwann cells whereas the chief cells produce and can release catecholamines and other neurotransmitter substances.19,48 The tumors that arise from these cell rests, the...

Latissimus Dorsi Flap

The latissimus dorsi (LD) muscle originates from the six caudal thoracic spines and fascia, the lumbar spines and fascia, and the posterior iliac crest. It inserts into the humerus. Its blood supply is from the thoracodorsal artery, accompanied by the thora-codorsal vein and nerve. The neurovascular pedicle enters the undersurface of the muscle 6 to 11.5 cm distal to the origin of the subscapular artery and 1.0 to 4.0 cm medial to the anterior border of the muscle. The thoracodorsal artery...

Local Flaps

Local flaps consist of tissue that is mostly detached from surrounding tissue but retains enough connec Figure 18-6. A, A patient with dermatofibrosarcoma of the scalp was reconstructed with pericranial flap and split-thickness skin graft which have healed well. B, Tissue expander in place and scalp fully expanded. C, Appearance after excision of skin graft, removal of tissue expander and advancement of expanded scalp. tion to preserve an adequate blood supply to the entire flap. These are...

Malignant Melanoma

The incidence of malignant melanoma in the United States increased by approximately 69 cases per year during the 1970s and by approximately 39 cases per year during the 1980s and 1990s.70 The death rate from melanoma, however, has not changed during that period, suggesting the impact of more aggressive efforts at early detection. Approximately 20 percent of these tumors involve the head and neck region and occur in patients in their fifth and sixth decades of life.71-73 Like non-melanomatous...

Malignant Schwannomas

While the majority of schwannomas are benign in their clinical behavior, approximately 5 percent of them manifest malignant clinical behavior with a Figure 16-17. A, Plexiform neurofibromat. B and C, MRI of plexiform neurofibromat. small minority of these arising within the head and neck.74,83 These malignant variants can demonstrate high mitotic activity, aggressive local infiltrative growth with a high recurrence rate, pulmonary metastases, and direct intracranial extension.74,76,83,84 The...

Muscle And Musculocutaneous Flaps

The development of muscle and musculocutaneous flaps resulted from an understanding of the blood supply to muscles and their overlying skin segments.26,27 This development in reconstructive surgery has significantly maximized flap survival and allowed reconstruc tion of larger head and neck defects that could not be covered with local flaps alone.28 A complete muscle or a muscle segment may be rotated or transposed into a defect, based on its own inherent blood supply. The muscle surface may be...

Nonsurgical Therapy

If one excludes carcinoma of the nasopharynx for which radiotherapy and chemotherapy are extremely effective (see chapter on Cancer of the Nasopharynx), there is a paucity of data on the use of non-surgical modalities specifically for the treatment of malignant tumors involving the middle cranial base. However, if one considers tumors of specific his tologies such as glomus tumors, neurilemmomas, and juvenile nasopharyngeal angiofibromas (JNAs), whose resection occasionally requires access to...

Nonsurgical Treatment

Radiation is the primary nonsurgical treatment for stage I and II laryngeal cancer. Chemotherapy plays a very small role except in certain bulky T2 tumors which would require a total laryngectomy for resection. The role of combination therapy involving chemotherapy and radiation will be discussed extensively in the next chapter. Figure 9-17. A, Endoscopic view of a right-sided T1 vocal cord lesion amenable to endoscopic excision. B, Endoscopic view after resection of the lesion. Surgical...

Oxygen Effect

The ability of ionizing radiation to cause biologic change is very much dependent on the amount of oxygen present in the tissue environment. Oxygen is the most potent radiosensitizer known at this time. Cells in a 100 percent oxygen environment are 3 times more radiosensitive than cells in complete anoxia. It is the oxygen that reacts with the DNA damage and prevents its repair which ultimately leads to cellular death. Figure 21-3. Cell survival curves for differing mitotic stages showing the...

Pain

Pain is a common complaint among patients with cancer, especially patients with head and neck cancer. Pain can be acute, as a consequence of surgery, or chronic, as in shoulder disability secondary to accessory nerve sacrifice (Figure 23-2).52,53 Pfister and colleagues found a 31 percent prevalence of frequent or persistent pain in a cross-sectional analysis of 194 treated patients, 67 percent of which was moderate or great in intensity. Pain scores tend to improve with time in this population,...

Palatal Augmentation Prostheses

Patients who have undergone glossectomies with or without microvascular free-flap (radial forearm) reconstruction can improve consonant speech phonemes k,g and swallowing ability with the aid of a palatal augmentation (tongue) removable prosthesis (Figure 20-11). This can be considered when the remnant dorsum of the tongue (or reconstructed tongue with a flap) cannot make contact with the junction of the hard and soft palate. For optimal results, the patients will benefit with additional speech...

Paramedian Forehead Flap

This axial flap is commonly used for external coverage in nasal reconstruction. It is based on the supra-trochlear artery and vein, running on the undersur-face of the flap.19 The flap is designed using a precise template of the missing nasal subunits and is placed on the contralateral forehead. Usually the distal third of the flap is elevated subcutaneously the middle third includes part of the frontalis muscle, and from 1 cm above the supraorbital rim, flap elevation is in the subperiosteal...

Patient Factors

Patient factors such as occupation, mental status, health status and wishes of the patient all guide treatment decisions. General medical condition is critical to the assessment process, particularly pulmonary function. Vocal quality may be more important to a person that uses their voice as part of their livelihood, Proximity of supraglottic cancer to commissure Patient wishes Medical condition Occupation Distance from treatment facilities Mental status of patient Skills of surgeon and...

Posterior Pharyngeal Wall

This region is adjacent to the retropharyngeal space and is contiguous with the pharyngeal wall of the oropharynx with superior extension to the base of skull and inferiorly to the cervical esophagus. Primary tumors in this region are usually large and infiltrate deeply along the retropharyngeal space with lymph node metastasis in the retropharyngeal and cervical nodes. Because of the extent of most of these tumors at presentation, surgical resection is usually not possible. Radiation therapy...

Postoperative Radiation Dosage

All patients undergoing postoperative radiation therapy for the high-risk indications noted previously for the primary tumor site and or the neck lesion receive conventional fractionation of 180 to 200 cGy per fraction, one fraction per day, 5 days per week to a total dosage of 6,000 to 6,300 cGy to the high-risk areas, and 5,000 to 5,400 cGy for elective nodal irradiation. This is based on published data from a randomized prospective trial by Peters and colleagues from M.D. Anderson Cancer...

Principles of Treatment

The extent of surgical resection for scalp tumors depends largely upon the depth of infiltration by the tumor. Excision through partial thickness of the scalp can be carried out for superficial tumors while excision through the entire thickness of the scalp including the periosteum may be necessary in deeply infiltrating tumors. On the other hand, tumors that are adherent to or involve the underlying cranium must have removal of the outer table of skull or a through-and-through resection up to...

Radiation Therapy

Conventional techniques have delivered radiation using external beam therapy, brachytherapy or a combination of both. More recent advances include altered fractionation schedules, radiation combined with chemotherapy or other sensitizers, and the use of accurately targeted beams with three-dimensional treatment planning or intensity-modulated radiotherapy. Important considerations in the delivery of radiation therapy include determination of adequate treatment volume (initial portals),...

Rectus Abdominis

Various designs of musculocutaneous flaps may be transferred as free flaps based on the rectus abdominis muscle, supplied by the deep inferior epigastric artery and vein and the periumbilical perforators69 (Figure 18-28). The rectus abdominis muscle is flat and thin, with a large skin island over the muscle that may be oriented in a vertical transverse or oblique fashion. In addition, one or more cutaneous paddles may be used to cover multiple surfaces of complex multidimensional defects in the...

References

Ridolfi RL, Lieberman PH, Erlandson RA, Moore OS. Schneiderian papillomas a clinicopathologic study of 30 cases. Am J Surg Pathol 1977 1 43-53. 2. Mashberg A. Erythroplasia the earliest sign of asymptomatic oral cancer. J Am Dent Assoc 1978 96 615-20. 3. Shafer WG, Waldron CA. Erythroplakia of the oral cavity. 4. Silverman S Jr, Gorsky M. Proliferative verrucous leuko plakias a follow-up of 54 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997 84 154-7. 5. Batsakis JG, Suarez P,...

Risk Factors and Etiology

Soft-tissue sarcoma of the head and neck (STSHN) is a disease most prevalent in adults and none of the risk factors commonly associated with squamous cell carcinoma are known to be involved in the pathogenesis of these tumors. Epidemiologic studies have identified genetically predisposed groups of individuals such as those suffering from neurofibro-matosis who are at risk of malignant peripheral nerve sheath tumor (MPNT), people with the Li-Fraumeni syndrome and children with retinoblas-toma...

Sequelae and Rehabilitation

The morbidity of surgical resection of tumors of the middle cranial fossa, irrespective of the surgical approach that is chosen, relate to paralysis or paresis of the lower cranial nerves as well as the facial mimetic musculature.52 If vagus nerve injury or sacrifice occur, paralysis of the pharynx, palate, and the vocal cord will ensue. In many instances, the initial breathiness and aspiration of liquids that can occur will gradually resolve as there is compensatory movement of the...

Sequelae Complications And Their Management

Although modern anesthetic and surgical technique has greatly increased the safety of surgery for oropharyngeal tumors, careful planning and meticulous technique are vital to successful outcome. The most common complications of surgery arise due to difficulties associated with inadequate exposure and the failure to anticipate the need for reconstruction. Incisions must be planned to take previous surgery and or radiation into consideration. It is important to resist the temptation to close a...

Soft Tissue Reconstruction

Many patients that undergo mandible resection for cancer have significant soft-tissue involvement of the floor of mouth and the tongue by tumor. Resection of the intraoral mucosal lining can lead to scarring and immobility of the remaining portion of tongue, which can create significant functional problems. Recreation of an adequate buccal sulcus will allow use of dentures postoperatively, and will maintain space for placement of osseointegrated implants. Loss of soft tissue in the submental...

Soft Palate Speech Bulb Prostheses

Defects of the soft palate usually require maxillofa-cial prosthetic intervention. Palatopharyngeal closure normally occurs when the soft palate elevates and contracts the lateral and posterior pharyngeal walls of the nasopharynx.27 When a portion of soft Figure 20-8. A, Six months post-maxillectomy. B, Definitive obturator. C, Definitive obturator in occlusion. palate is excised or when the soft palate is perforated, scarred, or neurologically impaired, complete palatopharyngeal closure cannot...

Sphenoid Sinus

Early lesions with disease confined to the sphenoid sinus can be approached surgically through either a sub-labial or lateral rhinotomy approach. A cutting burr is then used to achieve a good exposure, which will allow dissection of the tumor. Disease extending into the surrounding anatomy sometimes can be resected using an infratemporal approach and a craniotomy. In both circumstances, postoperative radiation therapy within 6 weeks following the procedure will be necessary. Primary radiation...

Squamous Cell Carcinoma

Squamous cell carcinoma is the most common malignancy of the sinonasal tract. These tumors are more common in men than in women with a peak incidence between 60 to 70 years of age. There is an association between sinonasal squamous cell carcinoma and nickel exposure. Workers at a nickel refinery in Norway developed squamous cell carcinoma at 250 times the expected rate, with a latent period varying from 18 to 36 years.14 Although tobacco and alcohol are major risk factors for squamous cell...

Subglottic Larynx

Primary subglottic larynx cancers account for only 4 to 6 percent of all larynx cancers. Most lesions involving the subglottic region represent transglottic extension of glottic malignancies. It is uncommon for primary subglottic cancers to present at an early stage as they are asymptomatic until quite advanced. The risk of lymph node metastasis is 20 to 30 percent with bilateral involvement being common. T1 lesions are those that are confined to the subglottis and T2 lesions involve the vocal...

Surgery

The most common perioperative complications which may accompany surgical resection of sinonasal malignancies include intraoperative or postoperative bleeding, wound infection, cere-brospinal fluid leak, and visual or orbital injury if orbital preservation was planned. Visual complications including diplopia, lacrimal duct dysfunction, ectropion, and exposure keratopathy may occur in cases of maxillectomy with orbital preservation. Local morbidity from a maxillectomy defect depends on the extent...

Surgical Management of the Orbit

The specific indications for orbital preservation and exenteration have evolved over the past 40 years and remain a controversial subject. Although in the 1950s the orbit was almost routinely exenterated for any extension of maxillary sinus carcinoma toward the orbital floor, the emerging consensus is that the Table 11-1. SURGERY AND RADIATION THERAPY Table 11-1. SURGERY AND RADIATION THERAPY RT radiation therapy SCC squamous cell carcinoma. RT radiation therapy SCC squamous cell carcinoma....

Surgical Treatment

Successful outcome after surgery should provide the patient with durable locoregional control of the disease and minimal functional deficit. This depends on meticulous planning with accurate mapping of both surface and deep extent of the tumor. The anatomic extent of the surgical defect must be anticipated in all dimensions, and the need for reconstructive effort considered prior to surgery. The approach chosen must afford good exposure, both for accurate and complete resection of the lesion...

The Algorithm For Reconstruction of Mandibular Defects

Scapular Soft Tissue Flap

Our experience clearly indicates that osseous free flaps have a very high success rate and should be used for most primary mandible reconstructions. The functional and esthetic outcomes are good-to-excellent for the majority of patients. The algorithm for flap selection is driven principally by the extent and site of bone and skin soft tissue loss. (Figure 19-7). The fibula donor site should be the first choice for a vast majority of patients, particularly those with large bony defects...

Timing of Reconstruction

In the past, most mandibular reconstructions were delayed because of the inability to transfer tissue immediately. A rationalization for this approach included the idea that sufficient time should be allowed to get through the period for highest risk of local recurrence. This is now considered purely an excuse for inadequate reconstructive techniques. The idea that one should wait to see if the cancer recurs prior to performing the reconstruction is also invalid since contemporary techniques of...

Treatment Goals And Alternative Factors Affecting Choice Of Treatment

The treatment goals should be assessed individually for each patient prior to embarking on any course of therapy. These decisions should include careful consideration of many factors including (1) histology of the tumor, (2) tumor stage, (3) feasibility of a com plete surgical resection, (4) the patient's underlying medical condition, (5) associated treatment risks and morbidity, (6) reconstructive options for the restoration of form and function, (7) socioeconomic issues, (8) the surgeon's...

Treatment

Determining the optimal treatment for olfactory neuroblastoma is complicated somewhat by the variable clinical course that these tumors can adopt. Some demonstrate a very prolonged clinical course with relapses and recurrences over many years, while others grow in a much more aggressive pattern with rapid and massive local, regional, and distant disease recurrence.92 In spite of this unpredictable clinical behavior, the treatment of choice for Figure 16-21. Esthesioneuroblastoma on MRI showing...

Tumors And Cysts Of The Dentoalveolar Structures

About 9 percent of all tumors in the oral cavity are odontogenic and may differentiate toward epithelial or the odontogenic ectomesenchymal line and are classified accordingly (Table 2-5). They are predominantly benign with rare exceptions. Ameloblastoma is a locally aggressive, usually intraosseous tumor of odontogenic epithelium most commonly involving the posterior part of mandible and sometimes the posterior maxilla. The tumor affects both sexes at all ages, with a higher incidence in the...

Unknown Primary

No discussion of head and neck imaging would be complete without a discussion of the occult primary presumed to be within the upper aerodigestive tract. If one looks at the larger picture of patients with metastatic adenopathy above the clavicles, the role of imaging has increasing value. CT of the neck, chest, abdomen and pelvis usually follows the traditional method of panendoscopy and exam under anesthesia after an unproductive office exam. The advent of FDG-PET can obviate the need for such...

Cancer of the Nasopharynx

Nasopharyngeal carcinoma is rare in the United States, with an annual incidence of 0.6 per 100,000 people. The incidence in Southern China is 50 times higher than in the United States.1 Native people of North Africa, the Middle East, Alaska, and Malaysia have an intermediate risk. The peak incidence for this cancer occurs in the fourth to fifth decade of life but it may occur in children and in the elderly. The male to female ratio is 2 to 3 1. The etiology of nasopharynx cancer is thought to...

Differentiated Thyroid Cancers

The two primary types of differentiated thyroid cancers are papillary and follicular. Several variants exist and include a follicular variant of papillary carcinoma, a tall cell variant of papillary carcinoma and a Hurthle cell carcinoma which is a variant of follicular carcinoma. The latter two subtypes are more ominous lesions. Primary surgery is the initial treatment approach. The surgical therapeutic decisions are based on prognostic variables. At Memorial Sloan-Kettering Cancer Center,...

Types of Therapeutic Radiation

There are two main categories of ionizing radiation and each contains several subtypes of clinical importance (1) electromagnetic radiation (photons) x-rays, gamma rays, and (2) particulate radiation electrons, neutrons, protons. The electromagnetic radiation subtypes do not differ in any physical characteristic or in their biologic action. The only distinction is in how they are each produced. X-rays are created by linear accelerators and involve an electrical input that causes a filament to...

Role of Chemotherapy and Organpreserving Approaches

Although numerous randomized trials have failed to demonstrate any survival benefit for neoadjuvant or sequential chemotherapy schedules, the major spinoff of the neoadjuvant approach was the observation that function of important structures such as the larynx and tongue could be preserved without compromising local control or survival.26 More recently, the radiosensitizing effects of chemotherapy have been exploited in designing concurrent chemoradiation protocols, and 3-year local control...

Chemotherapy and Radiotherapy

Treatment protocols using chemo RT to preserve organ function have successfully demonstrated their ability to anatomically preserve the larynx without compromising survival. One aspect of these protocols that is often underappreciated is the functional capacity of the retained organs. Few investigators have clearly documented the functional sequelae of chemotherapy and radiation therapy. Recently, Lazarus retrospectively studied patients being treated with chemotherapy and radiation therapy and...

Chemotherapy for Advanced Tumors

In attempts to improve the survival rates and local control of advanced sinonasal tumors, chemotherapy has been administered as an adjuvant treatment in a wide variety of methods. Chemotherapy has been given (1) with radiation and daily tumor debridement,33-36 (2) by topical application,35 (3) selectively to the head and neck through intra-arterial infusion,3337-39 (4) as a neoadjuvant treatment prior to further local treat-ment,40-42 and (5) concomitantly with hyperfraction-ated radiation...

Chemotherapy with Maxillary Debridement

Chemotherapy has been incorporated into numerous different treatment regimens with varying agents, methods of delivery, and combinations with radiation and or surgery. In the 1970s several groups in Japan began trying a combination of chemotherapy, radiation therapy and routine tumor debridement or cryosurgery within the maxillary sinus. The regimens included 5-fluorouracil (5-FU) or cisplatin with delivery through intravenous,3436 selective intra-arterial,33 and topical methods.35 Responses to...

Neoadjuvant or Concurrent Chemotherapy

Despite the encouraging results described above, both routine tumor debridement and intra-arterial cannula-tion present technical demands and may not be available for widespread use. Chemotherapy may be administered intravenously as a neoadjuvant agent prior to treatment with other modalities. LoRusso gave 24 patients with stage III or IV disease various chemotherapy combinations, including 5-FU and cisplatin, and followed this with surgery and or radiation therapy. Overall 5-year survival was...

Chemotherapy and Chemoprevention in Head and Neck Cancer

MALUF, MD ERIC SHERMAN, MD DAVID G. PFISTER, MD For most epithelial tumors of the head and neck, surgery and or radiation therapy have historically been the principal treatment modalities. Systemic drug therapy alone in most instances does not have curative potential, and previously had been reserved for the palliative treatment of recurrent and or distant metastatic disease. Over the last decade, this has changed dramatically, especially for squamous cell carcinomas of the upper...

Chemotherapy for Salivary Gland Cancers

Major and minor salivary gland cancers represent approximately 5 to 10 percent of head and neck malignancies.134 135 In general, surgery and or radiation have been the principle treatment modalities, with chemotherapy primarily used in the recur-rent metastatic disease setting. As a single modality, chemotherapy is not curative. Because of the relative rarity and heterogeneity of these tumors, the available data on the efficacy of systemic therapy is often of poor quality. Many series are...

Pathology

Noninvasive imaging can reliably diagnose some soft-tissue lesions such as lipomas, benign vascular tumors, and fibromatosis. For most other tumors, histologic examination of a biopsy specimen is currently the only reliable technique that can lead to a definitive diagnosis. Several techniques are in common use fine-needle aspiration (FNA), core needle biopsy, incisional biopsy and excisional biopsy. FNA is the easiest to perform and can be safely undertaken at the first clinic visit of a...

Neurogenic and Vascular Tumors of the Head and Neck

SHAH, MD, FACS Neurovascular tumors of the head and neck are a varied group of neoplasms that can present clinically as isolated masses or in association with various familial syndromes. The majority of neurovascular tumors are benign lesions that can potentially exhibit local destruction from expansile growth, while some are overtly malignant, with aggressive growth capabilities and obvious metastatic potential. While the treatment for these lesions is...

Cancer of the Hypopharynx and Cervical Esophagus

The management of malignant neoplasms of the hypopharynx and cervical esophagus remains difficult despite recent advances in surgical techniques as well as multidisciplinary treatment programs. Many patients present at a later age with advanced disease due to the occult nature of associated symptoms. The disease process and treatment often affect adjacent structures, such as the larynx. Regardless of the type of therapy employed, high recurrence rates, poor survival, and significant alterations...

Chemotherapy for Thyroid Cancer

As with salivary gland tumors, thyroid cancer constitutes a spectrum of histologic subtypes and clinical Table 22-10. COMBINATION CHEMOTHERAPY IN SALIVARY GLAND CANCER CDDP 5-FU CDDP DOXO 5-FU CDDP EPI 5-FU or CTX CTX DOXO CTX DOXO CDDP Adenoid cystic Mucoepidermoid Mucoepidermoid 'Variable 'Variable 'Variable 'Variable * Variable includes adenoid cystic carcinoma and mucoepidermoid carcinoma as the most common histologies. BLM bleomycin CDDP cisplatin CT chemotherapy CTX cyclophosphamide DOXO...

Rehabilitation and Quality of Life Assessment in Head and Neck Cancer

In 1947, the World Health Organization (WHO) expanded its definition of health beyond the absence of disease and infirmity, to include the state of physical, mental, and social being. This milestone change in connotation elevated the study of health-related quality of life to an accepted endpoint for clinical studies and promulgated investigator interest.1,2 Reflecting its increased use in medical studies, quality of life was introduced as a category in the Index Medicus in 1966.1 Since then,...

Neutron Therapy

This densely ionizing high linear energy transfer particulate radiation has a limited but important role in clinical radiation oncology. Fast neutrons can be contrasted to photons in th following ways 1. the biologic effectiveness is much less influenced by hypoxic environments. 2. lethal effects are less dependent on the cell cycle phase. 3. the ability of malignant cells to repair sublethal damage matters less. 4. is biologically more effective with a relative biologic effectiveness (RBE) of...

Factors Affecting Choice of Treatment

Because of anatomical constraints and the radiosen-sitivity of carcinoma of the nasopharynx, primary surgical resection is not indicated. Radiation therapy is the principal treatment modality for curative therapy and may also be used to palliate local symptoms. Chemotherapy has been studied as an adjuvant to primary radiotherapy and serves as systemic treatment for patients with disseminated disease. The basic treatment of nasopharynx cancer has consisted of radiation therapy alone for many...

Cancer of the Head and Neck

Shah, MD, MS (Surg.), FACS, Hon. FRCS (Edin), Hon. FDSRCS (Lond) Chief, Head and Neck Service E.W. Strong Chair in Head and Neck Oncology Memorial Sloan-Kettering Cancer Center Professor of Surgery, Weill Medical College, Cornell University New York, New York Assistant Editor Snehal G. Patel, MD, MS (Surg.), FRCS Clinical Research Associate Head and Neck Service Memorial Sloan-Kettering Cancer Center New York, New York 2001 BC Decker Inc Hamilton London BC Decker Inc 20 Hughson Street...

Glottic Larynx

Squamous cell carcinoma in situ of the true vocal cords is initially treated surgically, and usually with micro-excision. However, if there is evidence of microinvasive squamous cell carcinoma in the specimen or if there are rapid or multiple recurrences, radiation therapy can be administered with an approach identical to that for T1 invasive lesions. Wang24 reported a 92 percent 5-year local control and a 98 percent 5-year disease-free survival. The results in voice quality are good. T1...

Relationship of Cell Cycle and Ionizing Radiation

The cell cycle (Figure 21-2) has four phases that are distinctly sequenced and describe the life cycle of cells (1) Synthesis (S) DNA synthesis, (2) Gap (G2) a period of apparent cellular inactivity, (3) Mitosis (M) cellular division into two daughter cells, (4) Gap (G1) a period of apparent cellular inactivity. Cells vary in their sensitivity to ionizing radiation and this is dependent on their position within the cell cycle at the time of the exposure to the radiation (Figure 21-3). The most...

Concomitant Chemotherapy

The concomitant integration of chemotherapy and radiation therapy for the treatment of advanced disease has been one of the areas of greatest interest in head and neck oncology during the last decade. Potential radiation enhancement, the simultaneous treatment of both locoregional and distant disease in a dose-intense manner, and shorter treatment times make the approach particularly appealing. Interestingly, the approach is much older than the relatively recent surge in interest would suggest....

Selective Intraarterial Chemotherapy

The selective administration of chemotherapy through intra-arterial infusion offers the advantage of a more direct drug delivery to the tumor site at a higher local concentration than can be achieved with systemic therapy. This technique was initially attempted with modest results similar to those obtained by surgery and postoperative radiation ther-apy.53 Shibuya suggested that one problem was the multiplicity of feeding arteries supplying the maxillary sinus causing an irregular, lower...

Soft Tissue Tumors

Histologic typing and grading of STS is often difficult and a considerable degree of inter-observer variability exists even among expert pathologists with a reported diagnostic discrepancy in as many as 25 to 40 percent of lesions.12 The routine use of immunohistochemical stains has facilitated histologic classification, but these techniques are by no means definitive, and considerable experience is required in interpreting results. More objective methods such as cytogenetic, molecular and...

Bone Tumors

Orbital Cancer Invasion

Bone tumors are generally classified according to the matrix that their constituent cells produce eg, tumors that produce a cartilaginous matrix are classified as chondrosarcomas, those that produce osteoid are classified as osteosarcomas and others that lack a distinct matrix may be classified as fibrosarcomas. Chondrosarcomas and osteosarco-mas are by far the most common sarcomas involving the facial skeleton, but other rarer types such as Ewing's sarcoma and peripheral primitive...

Outcomes and Results of Treatment

The prognosis for sinonasal malignancies has remained poor for the past several decades despite refinements in both surgical technique and radiation therapy. Stern reviewed the M.D. Anderson experi- Figure 11-16. An intraoral view of a rectus abdominus free flap filling a left total maxillectomy defect. Facial contour following total maxillectomy is improved by the soft-tissue bulk of a rectus abdominus free flap reconstruction. Figure 11-16. An intraoral view of a rectus abdominus free flap...

Treatment Goals and Treatment Alternatives The Role of Multidisciplinary Treatment

Cure is the goal of treatment for most patients without distant metastases. Prognosis depends upon disease stage, histology, and biological factors such as degree of angiogenesis.9,14-16 Palliation of symptoms is a secondary goal for patients with curable disease and a primary goal for patients with distant metasta-tic disease. Palliative approaches range from supportive care to chemotherapy, radiation therapy and, rarely, surgical intervention. The optimal management of nasopharynx cancer...

Rehabilitation

The rehabilitation of function after oral surgery is a critical element in effective oral cancer surgery. After major oral resections the patients need rehabilitation of speech, swallowing, dentition and mastication as well as cosmesis. This process is best accomplished in a multidisciplinary environment which include the head and neck surgeons, plastic surgeons, speech and language therapists, nurses, dentists, prosthodontists and oral and maxillofacial surgeons. Perhaps the most important...

Sequential Chemotherapy

The sequential integration of chemotherapy with locoregional treatment can be done in three main ways as induction or neoadjuvant chemotherapy prior to surgery and or radiation, as an adjuvant after locoregional treatment, or as a combination of these approaches. Given the impressive response rates Table 22-1. PHASE I II TRIALS EVALUATING NEW CHEMOTHERAPEUTIC COMBINATION REGIMENS'ACTIVITY IN PREVIOUSLY UNTREATED PATIENTS WITH LOCALLY ADVANCED HEAD AND NECK CANCER Table 22-1. PHASE I II TRIALS...

Management of Leukoplakia

Effects Smoking Alveolar

During the carcinogenic process, some abnormal clonal populations of mucosal cells form clinical premalignant lesions. These are manifested as leukoplakia or erythroplakia. Leukoplakias are common lesions in smokers and patients with a previous history of head and neck cancer. These are also noted in patients without heavy carcinogenic exposure. In general, dysplastic leukoplakia should be treated while lesions harboring only hyperplasia and hyperkeratosis may be observed. Clinical...

Management of Cervical Metastasis

Postauricular Injection

ANDERSEN, MD, FACS SCOTT SAFFOLD, MD Head and neck cancer represents less than 5 percent of all cancers in the United States and will be responsible for approximately 11,800 deaths in 2001.1 However, worldwide it ranks as the sixth most common cancer,2 thus making head and neck cancer a major health problem. While the term head and neck cancer refers to tumors of myriad sites of origin and histologic types, over 90 percent of these are squamous carcinomas arising from the epithelium of...

The Role of Chemotherapy in Larynx Organ Preservation

Laryngeal Cancer Treatment

The trials evaluating induction chemotherapy, while disappointing with regard to improving survival as an endpoint, did provide the backdrop for current organ preservation strategies. Investigators observed that some patients refused surgery after initial chemotherapy and proceeded with radiation alone.87 Some of these patients were controlled over the long term without surgery, and there appeared to be a positive correlation between initial response at the primary site to induction...

General Principles of Reconstructive Surgery for Head and Neck Cancer

DISA, MD ERIC SANTAMARIA, MD PETER G. CORDEIRO, MD, FACS Current treatment of head and neck cancer follows a multidisciplinary approach. The principle of this combined approach is to provide the patient with the optimal cancer treatment for the stage of disease, and to maximize the quality of life for the patient, with preservation or restoration of form and function. Reconstructive surgical procedures developed over the past several decades have substantially contributed to attain...

General Considerations

Treatment of head and neck cancers has oral sequelae and treatment-related toxicities requiring intervention by dentists. Dental team intervention should begin prior to radiation therapy, surgical resection, and or chemotherapy. For optimal post-treatment oral functional outcomes, regardless of cancer therapies, a comprehensive dental assessment is para-mount.1 The multidisciplinary team should encompass trained dentists with interests and training in comprehensive oral dental care of the...

Cancer of the Nasal Cavity and Paranasal Sinuses

KRAUS, MD, FACS Cancers of the nasal cavity and paranasal sinuses are rare, comprising less than 1 percent of all human malignancies and only 3 percent of those arising in the head and neck.1 Sinonasal malignancies occur twice as often in males as in females, and are most often diagnosed in patients 50 to 70 years of age.2 The majority of these tumors are squamous cell carcinoma, although a wide variety of other malignancies including sarcoma, adenoid cystic...

Quality of Life Instruments

As the science of QOL assessment has matured, standardized testing has been implemented to validate QOL instruments, centered on establishing reliability, validity, and normative data.1 Reliability can best be defined as the usability of a particular instrument, which can be divided into four concepts namely test-retest reliability, alternate-form reliability, internal consistency, and interobserver reliability. Test-retest reliability measures the stability of the test over time. Typically,...

Clinical Course of Radiation Therapy

Xerostomia After Radiation

The patient undergoing radiation therapy will need to be seen for routine status evaluation at least once a week. At that time, a pertinent interval history is obtained with special attention paid to the development of a sore mouth or throat, dysphagia, hoarseness, taste problems, xerostomia, skin symptomol-ogy, and even ear symtoms when the portal includes the external auditory canal and or eustachian tube. A directed examination will evaluate the tumor status with measurements and an...

The Larynx Early Stage Disease

Laryngeal Cancer Staging

LYDIATT, MD, FACS DANIEL D. LYDIATT, DDS, MD, FACS The American Cancer Society estimated that in the United States there would be 10,600 cases of laryngeal carcinoma diagnosed in 1999, and 4,200 deaths.1 This accounts for 0.9 percent of cancers from all sites and 0.8 percent of all cancer deaths. Laryngeal carcinoma makes up 1 to 2 percent of cancers worldwide, and the incidence is increasing (Figure 9-1). Spain has one of the highest rates in the world with Basque and Navarra...

Pathology of Head and Neck Tumors

Histology Ducts Scheme

HUVOS, MD TUMORS OF THE UPPER AERODIGESTIVE TRACT MUCOSA Neoplasias of the upper aerodigestive tract histologically tend to mimic the normal constituent cells in this region. The most common neoplasias show differentiation toward lining epithelium. pressure. Synchronous or metachronous association with squamous cell carcinoma as well as progression to it may occur in some patients with inverted Squamous papilloma is a solitary papillary lesion of the squamous...

Thyroid and Parathyroid Tumors

Thyroid Berry Ligament

PATEL, MD, MS, FRCS Diseases of the thyroid gland represent a common medical and surgical problem. A variety of inflammatory lesions and neoplasms are noted by endocri-nologists and surgeons interested in thyroid pathology. Various pathologic conditions include Hashimoto's thyroiditis, nodular goiter, solitary thyroid nodule, adenomas and thyroid cancer. Although thyroid disease is extremely common, thyroid cancer is relatively uncommon and forms less than 2...

Epidemiology and Etiology

Oral Cancer Risk Smoking And Alcohol

The global incidence of cancers of the oral cavity, pharynx and larynx is about 500,000 cases per year with mortality of 270,000 cases per year.1 Excluding skin cancers, this represents about 6 percent of the incidence and 5 percent of the mortality of all cancers.1 About three-fourths of these are cancers of the oral cavity and pharynx and the remainder are laryn-geal cancers. Figure 1-1 describes the incidence of oral and pharyngeal cancers by world region. As demonstrated here, the areas of...

Case 7 Bilobed Flap

Necrotic Wound

The bilobed flap is a random flap but is excellent for coverage of various surgical defects throughout the Figure 4-10. A, The patient had undergone excisional biopsy of a malignant melanoma of the cheek elsewhere. The scar of previous excision was widely encompassed in the surgical incisions which were planned to provide access for a superficial parotidectomy. B An inferiorly based cervical Limberg flap has been elevated and the surgical bed of resection shows the branches of the facial nerve...

Patient Education Home Care Instructions Fluoride Application

Osteoradionecrosis

Oral hygiene procedures including scaling, polishing, sub-gingival root planing and curettage should be performed and home-care instructions and fluoride prescriptions given between the initial screening appointment and commencement of external beam radiation therapy (EBRT).7 In addition, overhanging and faulty Figure 20-2. Full mouth extractions post-radiation therapy with alveolectomy and primary closure. Figure 20-2. Full mouth extractions post-radiation therapy with alveolectomy and primary...

Surgical Treatment Resection

Pictures Esophageal Reconstruction

The difficulty in surgical treatment of advanced carcinoma of the hypopharynx and cervical esophagus arises from the common requirement for laryngectomy as part of the procedure. The larynx is removed because of direct or submucosal tumor extension and significant risk of chronic or life-threatening aspiration. Histopathologic studies of hypopharyn-geal cancer have shown that assessment of the extent of laryngeal disease based on endoscopic findings in the hypopharynx is inaccurate.50...