Oncology 2 Section 4-2

anatomy of the oral cavity

• extends from the skin vermillion junction of the lip anteriorly to the posterior border of the hard palate and retromolar trigone

• superior border is the hard palate

• inferior border is the circumvillate papillae (FOM)

• made up of:

  • anterior 2/3 of the tongue

  • floor of mouth

  • buccal mucosa

  • gingiva (upper and lower alveolar ridges)

  • retromolar trigone

  • hard palate

  • lip (vermillion)

lymphatic damage of lips

• submandibular

• pre-auricular

• facial

lymphatic drainage of buccal mucosa

• submaxillary

• submental

lymphatic drainage of gingiva

• submaxillary

• jugular

lymphatic drainage of retromolar trigone

• submaxillary

• jugulodigastric

lymphatic drainage of FOM

• submaxillary

• jugular

lymphatic drainage of anterior 2/3 of the tongue

• submaxillary

• upper jugular

general treatment of oral cavity cancers

• surgery if tumor is small (< 1-1.5 cm)

• RTT 50Gy to 70Gy typically w/ opposed laterals and boost fields

• hyperfractionation is often helpful

• chemo is common adjunct either after or concurrent w/ RTT

• IMRT/IGRT to escalate dose

borders for oral cavity cancers

• anterior: anterior portion of mandible excluding lower lip

• posterior: behind vertebral bodies or spinous processes

• superior: 1.5cm above the tongue

• inferior: thyroid notch

anatomy of the tongue (locations, areas)

• anterior 2/3 of the tongue is in the oral cavity

• base of the tongue is in the oropharynx

• composed of four areas:

  • tip

  • lateral borders

  • dorsum

  • undersurface

epidemiology/etiology of tongue cancers

• male predominant

• median age: 60, rare under 40

• typical H&N etiologies including Plummer-Vinson syndrome

presentation/symptoms/patterns of spread of tongue cancers

• leukoplakia/erythroplasia

• chronic non-healing painless ulcer

• most commonly present on the lateral borders of the anterior tongue

• may occasionally cross mid-line or extend into the base of the tongue

treatment of tongue cancers

• surgery (hemiglossectomy) is limited since excision has significant morbidities

• RTT

  • 60-75Gy depending on stage

  • subdigastric and submaxillary nodes must be included in the field

epidemiology of lip cancer

• almost always on the lower lip

• 90% occur in males

• incidence increases with age

etiology of lip cancer

• sun/UV radiation

• wind

• pipe/cigar smoking

• chronic irritation

presentation/symptoms of lip cancer

painless ulceration persistent for more than 2 weeks

treatment of lip cancer

RTT or surgery, better cosmetic results with RTT

etiology of FOM cancer

alcohol and tobacco

patterns of spread of FOM cancer

invasion of the mandible is common due to proximity to the primary tumor

treatment of FOM cancer

• often treated with resection

• recent studies indicate that good local control can be achieved through a combination of external beam RTT, brachytherapy, or intra-oral KV

etiology of buccal mucosa cancer

• chewing tobacco

• chronic biting of cheek

presentation/symptoms of buccal mucosa cancer

• most originate on the lateral walls

• most have a history of leukoplakia

  • more common here than in other parts of the oral cavity

• appear as a raised exophytic growth

• Stenson’s duct can become obstructed resulting in an enlarged parotid gland

treatment of buccal mucosa cancer

• surgery or RTT

• RTT often involves a single photon or electron beam (sparing contralateral tissues)

epidemiology of gingiva cancer

• majority occur in the lower gingiva

• female predominant - only oral cavity cancer that is female predominant

anatomy of hard palate

semilunar area between the upper alveolar ridge and the mucous membrane covering the palatine process of the maxillary palatine bones

epidemiology of hard palate cancer

more common in patients who have a history of ill-fitting dentures or trauma

presentation/symptoms of hard palate cancer

• difficulty in wearing dentures

• painful ulceration

pathology of hard palate cancer

adenocarcinoma

anatomy and epidemiology of retromolar trigone

• triangular area behind the last molar tooth

• carcinomas in this area are extremely rare

regions of the pharynx

• nasopharynx

• oropharynx

• hypopharynx

most common presenting symptoms of pharyngeal cancers

• persistent sore throat

• painful swallowing

• referred otalgia

• enlarged cervical lymph nodes may be present

anatomy of nasopharynx

• are below the base of the brain, posterior ot the nasal cavity, and above the soft palate

• includes the adenoids

• extends on a line from the zygomatic arch to the EAM

• nasal cavity drains into the nasopharynx

• often difficult to examine

epidemiology/prognosis of nasopharyngeal cancer

• highest incidence in China and middle eastern countries

• overall 5 year survival: 45%

etiology of nasopharyngeal cancer

• not associated w/ tobacco use

• Epstein-Barr Virus

presentation/symptoms of nasopharyngeal cancer

• painless neck mass

• nasal obstruction and bleeding

• ear pain and hearing loss (due to obstruction of Eustachian tube orifice with otitis media)

• sore throat

• headache

• facial pain

• cranial nerve abnormalities frequently occur (an indication of advanced disease)

• 3rd and 6th cranial nerve paralysis (eye movement)

patterns of spread/mets/lymphatics of nasopharyngeal cancer

• local invasion along lateral pharyngeal walls into oropharynx and/or into base of skull and sphenoid sinus

• unlike most H&N, fair number of patients have blood-borne mets in addition to aggressive local invasion

• vast majority of patients (75-85%) have positive cervical nodes at diagnosis

  • jugulodigastric

  • posterior cervical

  • retropharyngeal nodes

    • lateral AKA Rouvier’s node

treatment of nasopharyngeal cancer (modalities, fields, doses, chemo)

• RTT is most commonly used

  • not accessible to surgery

  • chemo is largely ineffective

• large parallel opposed lateral fields to encompass nasopharynx, all surrounding structures and bilateral neck nodes to clavicles via supraclavicular field, including the base of the brain and posterior 1/3 of the orbit and Rouvier’s node

• doses:

  • 65Gy

  • 70Gy if there are positive nodes or bulky disease

• concomitant chemo should be used with RTT for stages 2 and 4 to increase chance of local control

• retreatment of local failures with external beam followed by brachytherapy is considered feasible

RTT borders of nasopharyngeal cancer

• superior: 2 cm beyond tumor, as seen on a CT scan, to include base of skull and sphenoid sinuses

• posterior: 2 cm margin beyond mastoid process or extending further to allow a 1.5 cm margin on enlarged nodes

• anterior: include the posterior third of the maxillary sinus and nasal cavity with adequate 2 cm margin for more anterior tumors

• inferior: thyroid notch to allow sparing of larynx

• lower neck: anterior supraclavicular field w/ larynx block

anatomy and regions of oropharynx

• extends from the soft palate to the hyoid bone

• regions:

  • soft palate

  • uvula

  • tonsil

  • posterior 1/3 (base) of tongue

  • pharyngeal walls

epidemiology/etiology of oropharyngeal cancer

• tonsil is most common primary site

• smoking and heavy alcohol consumption are especially prevalent in this patient population

presentation/symptoms of oropharyngeal cancer

• sore throat and painful swallowing are most common

• enlargement of cervical nodes occur in 20-30% of cases

• referred otalgia

lymphatic drainage of base of tongue

• jugulodigastric

• lower cervical

• retropharyngeal

lymphatic drainage of tonsils

• jugulodigastric

• submaxillary

lymphatic drainage of soft palate

• jugulodigastric

• submaxillary

• spinal accessory

lymphatic drainage of pharyngeal walls

• retropharyngeal

• pharyngeal

• jugulodigastric

treatment of oropharyngeal cancer (doses, borders)

• RTT is most commonly used (66-82Gy depending on location and stage)

  • hyperfractionation: 70Gy

  • clinically negative nodes: 50-54Gy

  • w/ node dissection: 60Gy

  • spinal cord block at 45Gy

• borders:

  • anterior: 2cm from known tumor

  • superior: 1.5cm to 2cm superior to the soft palate

  • posterior: posterior spinous process

  • inferior: level of the hyoid

• IMRT is replacing most conventional treatments

prognosis of oropharyngeal cancer

• tonsil and soft palate have best prognosis (about 50%)

• pharyngeal wall and base of tongue have poor prognosis

• overall: 35%

anatomy of hypopharynx

• pyriform sinuses

• post-cricoid region

• lower posterior pharyngeal wall

epidemiology/etiology/prognosis of hypopharyngeal cancer

• most lethal of H&N cancers

• pyriform sinus is most common site

• usually etiologic factors including Plummer-Vinson syndrome in women

• post-cricoid carcinomas have the poorest prognosis

presentation/symptoms of hypopharyngeal cancer

• odynophagia (pain on swallowing) - “hallmark” presenting symptom of post-cricoid carcinoma

• cervical mass is often the only symptom

detection/diagnosis of hypopharyngeal cancer

• visual inspection

• palpation

• biopsy

• fiber-optic endoscopy

• CT/MRI

lymphatic drainage of hypopharynx

• superior deep, middle, and low jugular nodes

• Rouvier’s node (lateral retropharyngeal)

treatment of hypopharyngeal cancer (modalities, borders)

• surgery or radiation for early lesions

• surgery and RTT with large fields and 70Gy for advanced lesions

• borders:

  • superior: inferior border of mandible and mastoid process to the base of skull

  • inferior: lower border of cricoid Cartilage, 1.5 to 2 cm margin

  • anterior: in front of the thyroid cartilage “Flash (Shine-over)” if the larynx is involved

  • Posterior: behind the spinous process

epidemiology/etiology of nasal fossa cancer

• rare

• higher incidence of adenocarcinoma is found in furniture workers

• chronic sinusitis and/or nasal polyps

presentation/symptoms of nasal fossa cancer

• nasal obstruction

• epistaxis AKA nose bleeds

treatment of nasal fossa cancer

RTT preferred for small lesions because of better cosmetic results (radioactive implants may be used)