head and neck case1

7/29/2019 Head and Neck Case1

1/19

HEAD and NECK Case1

Monica Kristine D. Reyes


2/19

Given

1. 45 year old man

2. 1x2cm firm, movable, non-tender mass: right side ofneck at level II.

3. Patient took no notice: thought it was reactive

lymphadenopathy (had cold).4. 4 weeks later: enlarged- 3x2cm

5. No other pertinent neck findings.

6. Posterior Rhinoscopy: reddish mass at the fossa of

Rosenmuller on the right (confirmed on nasalendoscopy)

7. Punch biopsy; undifferentiated CA


3/19

RecallLevel II: Skull base, Hyoid Bone, Submandibular Gland,

Sternocleidomastoid Muscle

The Level II lymph nodes extend from the skull base, at the lower levelof the bony margin of the jugular fossa, to the lower margin of thebody of the hyoid bone. Level II nodes are located anterior to a

transverse line connecting the posterior edge of thesternocleidomastoid muscles and posterior to a transverse lineconnecting the posterior edge of the submandibular glands.

Level IIA: These are Level II lymph nodes that are located anterior,medial or lateral to the internal jugular vein. These also define

Level II lymph nodes that are posterior to the internal jugular veinbut directly abut the vein(22, 23).

Level IIB: These nodes are posterior to the internal jugular vein andhave an identifiable fat plane between the lymph node and thevein(22, 23).


4/19


5/19


6/19

RecallRosenmuller fossa boundaries:

1. Anterior: Eustachean tube and levator veli palati muscle.

2. Posterior: Pharyngeal wall mucosa overlying thepharyngobasilar fascia and retro pharyngeal space,containing the retropharyngeal lymph nodes of Rouviere.

3. Medial: Nasopharyngeal cavity.4. Superior: Foramen lacerum and floor of the carotid canal.

5. Postero lateral (apex): Carotid canal opening and petrousapex posteriorly, foramen ovale and spinosum laterally.

6. Lateral: Tensor palati muscle, mandibular nerve and theprestyloid compartment of the para pharyngeal space.


7/19

Recall

Punch biopsy:

The use of a biopsy punch

in oral mucosal lesions is

described and may be of

some value. Punch biopsy

may be difficult on freelymovable oral tissues and

probably offers no

advantage compared with

scalpel biopsy. The

technique may be

appropriate in the hardpalate and other sites with

better support and tissue

that is bound down, and it

is likely to produce a

satisfactory specimen. The

wound heals by secondaryintention, and discomfort

may persist longer than

anticipated by the

clinician and the patient.


8/19

Diagnosis

Nasopharyngeal Carcinoma metastasizing to the

right cervical lymph nodes, level II

WHO-3 category


9/19

Differentials

I knowhindi tinatanongpero isama ko na rin

Look up spondylosis, benign mixed tumor of thesalivary glands, mucoepidermoid carcinoma

and cervical disc herniation

But since, nagbiopsy na ngaduh? =)


10/19

What personal and social history information would

contribute to the diagnosis? Sex. Men have about double the risk of developing cancer of the nasopharnyx as women do.

Race. This type of cancer more commonly affects people in Asia and northern Africa. In theUnited States, Asian immigrants have a higher risk of this type of cancer than do American-born Asians, which may be related to differences in diet. The Inuits of Alaska also have anincreased risk of nasopharyngeal cancer. Additionally, blacks are significantly more likely todevelop nasopharyngeal cancer than are whites.

Age. Most cases of nasopharyngeal cancer occur in people between the ages of 30 and 55.

Salt-cured foods. Chemicals released in steam when cooking salt-cured foods, such as fish,preserved vegetables and Chinese herbs, may enter the nasal cavity, increasing the risk ofnasopharyngeal carcinoma. In China, nasopharyngeal carcinoma has been linked to highconsumption of salted fish, and as people in Southeast China are adopting a more Westerndiet, their rates of nasopharyngeal cancer have been declining.

Preserved meats. Preserved meats contain high levels of nitrates, which may increase therisk of nasopharyngeal carcinoma. ; high incidence in those with low vegetable consumption

(carotenoids are protective) Epstein-Barr virus. This common virus usually produces mild signs and symptoms, such as

those of a cold. Sometimes it can cause infectious mononucleosis. Epstein-Barr virus is alsolinked to several rare cancers, including nasopharyngeal carcinoma. In fact, the Epstein-Barrvirus can be found in almost all nasopharyngeal cancer cells.

Family history. Having a family member with nasopharyngeal carcinoma increases your riskof the disease, though researchers aren't sure if this association is due to genetic or

environmental factors. Smoking and alcohol use (including smokeless tobacco)


11/19

Is a Neck mass common for this

diagnosis?

The most common physical finding is a neck

mass, which is observed in 80% of patients.

Painless firm lymph node enlargement is

present.

http://emedicine.medscape.com/article/988165

-overview
http://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overviewhttp://emedicine.medscape.com/article/988165-overview


12/19

Diagnostic Procedures1. Laboratories:

a. Routine blood work, chemistry profile, CBC, liver function tests (rarecases of hepatic metastasis)

b. EBV titers, IgA, IgG antibodies to viral capsid antigen (titers correlatewith tumor burden)

c. CSF exam: seeding of the tumor (if invasion to skull base is observed)

2. Imaging:

a. CT: tumor extension, erosion of skull base, cervical lymphadenopathy,bone imaging (distant metastases)

b. MRI: extent of tumor (intracranial extension)

c. PET: questionnable neck nodes

3. Biopsy

(WHO-3 is undifferentiated carcinoma, including lymphoepithelioma. Thisentity consists of malignant epithelial cells with lymphocytic

infiltration)


13/19

Other Histopathology Three subtypes of NPC are recognized in the World Health Organisation

(WHO) classification [20]:

type 1: squamous cell carcinoma, typically found in the older adultpopulation

type 2: non-keratinizing carcinoma

type 3: undifferentiated carcinoma

Most cases in childhood and adolescence are type 3, with a few type 2cases [21]. Type 2 and 3 are associated with elevated Epstein-Barr virustiters, but type 1 is not [22]. The Cologne modification of the WHOscheme by Krueger and Wustrow [23] includes the degree of lymphoidinfiltration. Types 2 and 3 may be accompanied by an inflammatoryinfiltrate of lymphocytes, plasma cells, and eosinophils, which areabundant, giving rise to the term lymphoepithelioma. Two histologicalpatterns may occur: Regaud type, with a well-defined collection ofepithelial cells surrounded by lymphocytes and connective tissue, andSchmincke type, in which the tumor cells are distributed diffusely andintermingle with the inflammatory cells. Both patterns may be present inthe same tumor.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1559589
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14/19

Treatment Options

1. Surgery: Due to the anatomical position of NPC and its tendency topresent with cervical lymph node metastases, it is not amenable tosurgery for local control. Biopsy of the involved lymph node is the usualsurgical procedure. The nasopharyngeal primary tumor is rarelybiopsied.

2. Chemotheraphy: NOTE- doxorubicin, methotrexate and

cyclophosphamide would produce infertility in boys (total dose ofcyclophosphamide 12 gm/m2) and possible anthracycline toxicity (totaldose of doxorubicin 360 mg/m2) (ok langmatanda nanaman siya e.);assess renal toxicitythis is usually for palliative care.

3. Radiotherapy:The degree of pituitary dysfunction obviously depends onthe radiotherapy field and, potentially, on the dose of radiotherapy but

some degree of hypopituitarism is expected. Furthermore, irradiation tothe neck would result in hypothyroidism for the majority of patients andirradiation to the oropharynx would result in xerostomia and resultantpoor dentition. The later may be relieved by amifostine, asdemonstrated in adult studies. (does not prevent distant metastases)


15/19

More info on Radiotherapy

Radiotherapy is given with megavoltage equipment after initial chemotherapy. Amaximum dose of 45 Gy is given to the clinical target volume, which is a 1 cmmargin around the MRI-detected primary site, and inferiorly down to the claviclesto include the lymph nodes. Treatment is given in two phases:

Phase I parallel pair (mostly lateral unless the tumor extends anteriorly betweenthe eyes). Eyes, brain and brain stem are shielded as much as possible. A mid-plane dose of 30 Gy in 15 fractions is given.

Phase II a lateral parallel pair or three-fields technique is used for the primarysite, delivering 15 Gy in seven fractions to the clinical target volume of the tumorwith a 1 cm margin. Brain stem and eyes should be shielded. Any overlap with theneck field should be shielded. A matching anterior neck node field is used todeliver a prescribed maximum subcutaneous dose of 15 Gy in seven fractions. Thespinal cord should be shielded in this field. This prescription for radiotherapy isused in Manchester, but it is recognized that higher doses may be used in somecenters, possibly to a total of 60 Gy to the tumor volume. In an current GPOHstudy, patients in complete remission (CR) after three courses of chemotherapy,will have their radiotherapy dosage reduced to 54 Gy instead of 59 Gy.


16/19

Management after Biopsy and

Rationale behind Tx option1. Physical exam of the throat: An exam in which the doctor feels for swollen lymph

nodes in the neck and looks down the throat with a small, long-handled mirrorto check for abnormal areas.

2. Nasoscopy: A procedure to look inside the nose for abnormal areas. A nasoscopeis inserted through the nose. A nasoscope is a thin, tube-like instrument with alight and a lens for viewing. It may also have a tool to remove tissue samples,which are checked under a microscope for signs of cancer.

3. Neurological exam: A series of questions and tests to check the brain, spinalcord, and nervefunction. The exam checks a persons mental status,coordination, and ability to walk normally, and how well the muscles, senses,and reflexes work. This may also be called a neuro exam or a neurologic exam.

4. Head and chest x-rays: An x-ray of the skull and organs and bones inside thechest. An x-ray is a type of energy beam that can go through the body and onto

film, making a picture of areas inside the body.5. MRI (magnetic resonance imaging): A procedure that uses a magnet, radiowaves, and a computer to make a series of detailed pictures of areas inside thebody. This procedure is also called nuclear magnetic resonance imaging (NMRI).
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17/19

6. CT scan (CAT scan): A procedure that makes a series of detailed pictures of areasinside the body, taken from different angles. The pictures are made by a computerlinked to an x-ray machine. A dye may be injected into a vein or swallowed to helpthe organs or tissues show up more clearly. This procedure is also called computedtomography, computerized tomography, or computerized axial tomography.

7. PET scan (positron emission tomography scan): A procedure to find malignanttumorcells in the body. A small amount ofradioactiveglucose (sugar) is injectedinto a vein. The PET scanner rotates around the body and makes a picture ofwhere glucose is being used in the body. Malignant tumor cells show up brighter inthe picture because they are more active and take up more glucose than normalcells do. PET scans may be used to find nasopharyngeal cancers that have spreadto the bone.

8. Laboratory tests: Medical procedures that test samples of tissue, blood, urine, orother substances in the body. These tests help to diagnose disease, plan and checktreatment, or monitor the disease over time.

9. Biopsy: The removal ofcells or tissues so they can be viewed under a microscope bya pathologist to check for signs of cancer.

Management after Biopsy and

Rationale behind Tx option
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18/19

Radio vs. Chemorad vs. Chemotherapy

Chemotherapy: for unresected tumors; improveslikelihood of disease compared to irradiation alone.

Even in the absence of survival improvement, thereseemed to be a correlation between response to the

chemotherapy and subsequent response to radiation(less distant metastases)- 3-fold decrease inmortality

Radiotherapy: 1.fixed neck nodes, 2. delayed more than8 weeks post-op for reconstruction, 3. open biopsy for

a positive neck node, 4. risk of recurrence aboveclavicles exceeds 20% (should be no later than 6 to 8weeks) -delikado


19/19

END

Nica =)

head and neck case1

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