Pictorial Lesson on Head and Neck Cancer

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Pictorial Lesson on Head and Neck Cancer

• H Lord

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Intra-Oral Tumours
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Intraoral Cancer

• The majority of intraoral tumours are
  concentrated in the relatively small 'drainage'
  areas (highlighted in blue) where saliva pools

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Leukoplakia

• Also known as smoker's keratosis, this
  premalignant tumour is marked by extensive,
  irregular, white thickening or plaques.
• The woman shown here habitually allowed
  cigarettes to burn down to the end against her
  lip. A carcinoma subsequently developed in this
  area

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Tumour Staging for lip and oral cavity
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Nodal Staging for Lip and oral cavity
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Squamous cell carcinoma of tongue

• Located on the lateral border of the tongue, as
  is common with these tumors, this nodular lesion
  was painless despite its being a well-established
  invasive tumour.

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Squamous cell carcinoma of retromolar region and
soft palate.

• The lesion on the alveolar ridge shows the
  typical features of a malignant ulcer, but that
  of the soft palate appears only as a white patch.

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Squamous cell carcinoma of floor of mouth

• Panoramic tomogram shows a localized area of bone
  destruction (arrow-heads) in the body of the
  mandible

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Bone scan

• The photodeficient area (arrowheads) corresponds
  to the area of bone destruction seen on the
  tomogram.
• The area of increased uptake, indicating the
  actual extent of bone invasion, is much greater,
  encompassing most of the mandible.

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Squamous cell carcinoma

• CT scan of squamous cell carcinoma involving the
  mandible (arrows).

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Squamous cell carcinoma

• These well-differentiated tumours demonstrate the
  variable stromal response that may be
  encountered, ranging from (a) a heavy, chronic
  inflammatory infiltrate surrounding the invasive
  tumour, or
• (b) an inflammation-free stroma marked by
  fibroblastic proliferation. Note the presence of
  numerous keratin pearls.

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Squamous cell carcinoma

• Poorly differentiated tumours are marked by
  sheets of immature cells and no evidence of
  keratinization.
• Neoplastic cells show extreme degrees of
  pleomorphism, often with bizarre mitoses

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Pharyngeal Tumours
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Staging of Pharyngeal Cancer
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Nodal Staging and Mets for nasopharyngeal Ca
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Squamous cell carcinoma of oropharynx.

• A 53-year-old woman presented with odynophagia
  and nasal regurgitation of food.
• Examination reveals a large, exophytic,
  ulcerative lesion of the left tonsil that
  diffusely involves the soft palate and uvula.
  Palatal insufficiency resulted from a fistula in
  the right soft palate extending into the
  nasopharynx.
• After treatment with combination chemotherapy,
  the lesion completely regressed, replaced by
  fibrous tissue, and the fistula closed. Treatment
  continued with definitive radiotherapy. The
  patient remains free of disease in long-term
  followup.

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Squamous cell carcinoma of nasopharynx

• A 64-yo woman presented with a persistent serous
  effusion of the right middle ear.
• Axial CT scan soft tissue mass in the right
  lateral aspect of the nasopharynx close to fossa
  of Rosenmuller, infiltrating deeply and involving
  the Eustachian tube.
• Fascial planes destroyed by the advancing
  neoplasm (compare with normal left side).

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Squamous cell carcinoma of nasopharynx

• Coronal CT section shows a tumour extending into
  the middle cranial fossa (medium arrow) and
  inferiorly through the inferior orbital fissure
  (short, thick arrow), which is markedly widened
  (open arrow).
• Tumour is also present in the superior aspect of
  the nasal cavity (thin arrow). There is a soft
  tissue thickening within the sphenoid sinus.

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Squamous carcinoma of nasopharynx

• A 35-year-old woman complained of nasal
  stuffiness.
• Sagittal T1-weighted MRI image shows a large soft
  tissue mass (arrows) involving the sphenoid
  sinus, ethmoid sinus and clivus

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Boney destruction

• CT scan shows the extent of bony involvement of
  clivus petrous temporal bone sphenoid bone and
  ethmoid

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Squamous cell carcinoma of oropharynx

• A 63-year-old woman presented with difficulty in
  swallowing and otalgia.
• Examination reveals an extensive lesion of the
  right tonsil that involves the lateral pharyngeal
  wall, as well as the soft palate and uvula.
• After biopsy, which confirmed the diagnosis, the
  lesion was outlined (tattooed) with India ink and
  treated with combination chemotherapy and
  radiotherapy.

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Response to treatment

• This photograph, taken after chemotherapy but
  before radiotherapy, shows complete clinical
  regression of the tumour

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Laryngeal Tumours
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Staging of Laryngeal Tumours
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Squamous cell carcinoma of larynx

• Axial CT scan at the level of the posterior
  lamina of the cricoid cartilage (arrow 1) shows
  subglottic extension of an intralaryngeal tumour
  mass (arrow 2). The thyroid cartilage is
  indicated (arrow 3)
• Section through the glottis (about 1 cm cephalad
  to the previous scan) shows that necrotic tumour
  extends anteriorly into the soft tissue of the
  neck. The central portion of the thyroid
  cartilage has been destroyed.
• The tumour encroaches on the airway and has
  obliterated the anterior commissure. This is
  classified as a T4 lesion.

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Squamous cell carcinoma of larynx

• A 68-yo man, long history of alcohol and tobacco
  use, progressive dysphagia and hoarseness.
  Laryngoscopy reveals a large exophytic lesion of
  the supraglottic larynx that involves the
  aryepiglottic fold, the false vocal cord and the
  infrahyoid epiglottis.
• The true glottis is obscured but immobile. With
  the discovery of several small ipsilateral
  cervical lymph nodes, the patient was felt to
  have stage IV (T3N2b) disease.
• Radiotherapy was administered when the patient
  refused surgical resection. 28 months after
  radiotherapy, there is no evidence of tumour.

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Sinus Tumours
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Staging of Tumours of the Sinuses
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Squamous cell carcinoma of maxillary sinus

• Coronal CT scan shows intraorbital extension from
  a large carcinoma arising in the right maxillary
  sinus. The tumour extends medially into the nasal
  cavity, superiorly into the ethmoid labyrinth,
  and anterolaterally into the oral cavity.
• There is obvious extension of tumour into the
  orbit with destruction of the normal bony
  landmarks the floor of the orbit (roof of the
  maxillary sinus) is fragmented (compare with left
  orbit).
• In this plane, the bony floor of the anterior
  cranial fossa appears intact. A fluid level is
  present in the left maxillary sinus.

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Carcinoma of ethmoid sinus

• CT scans show a tumor expanding the ethmoid
  sinus, destroying the medial orbital wall and
  invading posteriorly into the middle cranial
  fossa.

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Esthesioneuroblastoma

• A 16-year-old boy presented with nasal
  obstruction of recent onset. (a) Axial CT scan
  shows a large expansile mass (arrows) in the
  right nasal cavity.
• The medial wall of the orbit is bowed outward,
  displacing the globe laterally. The anteromedial
  wall of the maxillary sinus is displaced but
  appears intact.

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Tumours of the Salivary Glands
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T categories and stage grouping for cancer of the
major salivary glands
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Pleomorphic adenoma of parotid gland.

• Clinically, as is common with these tumours,
  there is a painless swelling in this instance,
  the tumour involves the lower pole of the gland.

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Lymphoma
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Diffuse large cell lymphoma of oropharynx

• Additional evaluation of this 33-year-old man who
  presented with right tonsillar enlargement
  revealed only this jugulodigastric mass biopsy
  yielded the histologic diagnosis. For clinical
  stage II disease, he received six cycles of
  combination chemotherapy, which resulted in a
  complete response. He remains disease free 8
  years after treatment.

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Diffuse large cell lymphoma

• Clinical stage I disease. This axial MR scan
  reveals a soft tissue mass within the neck
  consistent with malignant regional adenopathy.
  The homogeneous texture of the lesion favours a
  diagnosis of lymphoma which was confirmed after
  an initial, unremarkable, evaluation of the head
  and neck mucosal surfaces under aneasthesia by a
  head and neck surgeon and subsequent excisional
  biopsy of the neck lesion.

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Diffuse large cell lymphoma of oropharynx

• A 24-year-old man, a non-smoker, presented with a
  3-week history of odynophagia and fatigue
  refractory to a trial of antibiotics.
• A massive necrotic lesion of the right tonsil is
  apparent. Intraoral biopsy yielded the histologic
  diagnosis