+

PSGS Review 2014

Surgery
Head and Neck
Ida Marie Tabangay Lim,MD
FPCS,FPSGS,FPAHNSI

THYROID GLAND DISEASES

+
ANATOMY
N

adult thyroid gland light brown in

color ; firm , weighs 15 to 20 g.

formed

by two lateral lobes

connected centrally by an isthmus.

the

lobes are 4 cm long, 2 cm wide,

and 20 to 40 mm thick, with the
isthmus 2 to 6 mm thick.

+
ANATOMY
Pyramidal

lobe - 80 percent of individuals; usually just to

the left of the midline, extending upward from the
isthmus along the anterior surface of the thyroid cartilage.
It is a remnant of the thyroglossal duct

+
ANATOMY

Blood supply : four major

arteries

superior

thyroid arteries- first

branch external carotid
artery

inferior thyroid arteriesarise from the thyrocervical

trunk of the subclavian arteries

Occasionally a fifth artery the thyroidea ima, originating

directly from the aortic arch or
the innominate artery.

VENOUS DRAINAGE:

Superior

thyroid vein
and middle thyroid
vein- internal jugular
vein

The

inferior thyroid
veins usually forming
a plexus that drains into
the brachiocephalic
vein.

+
Nerve Supply

Innervation of the gland is by sympathetic fibers from the

superior and middle cervical sympathetic ganglia. The fibers
enter with the blood vessels and are vasomotor in action.

Parasympathetic fibers are derived from the vagus nerve and

reach the gland via branches of the laryngeal nerves

+
Regulation of Thyroid Activity
Hypothalamic-pituitary-thyroid
axis (H_P_O)- the principal
homeostatic control of thyroid
hormone secretion .
Release of T 4 and T3 is stimulated by
thyrotropin or thyroid- stimulating hormone
(TSH) from the ant. pituitary
Secretion of TSH is directly suppressed by
T 4 and T3 (a negative feedback loop).
TSH release also is stimulated by the
hypothalamic hormone thyrotropin-releasing
hormone (TRH).

+
Thyroid hormone biosynthesis

+
Synthesis of Thyroid hormone

Steps in the synthesis of thyroid hormone are:

(1)

active trapping and concentration of iodide in

the follicular cell;
(2) rapid oxidation of iodide to iodine;
(3) linkage of iodine with tyrosine residues in
thyroglobulin;
(4) coupling of these iodotyrosines (monoiodoand diiodotyrosine) to form the active thyroid
hormones T 4 and T3.

+
The thyroid hormones

+
The thyroid hormones

BENIGN THYROID
DISORDERS

Benign Thyroid Gland

Disorders

THYROGLOSSAL DUCT ANOMALIES

HYPERTHYROIDISM
NODULAR GOITERS
SOLITARY THYROID NODULE
THYROIDITIS

+ EMBRYOLOGY OF THE THYROID

GLAND

Originates from the base of

the tongue

Caudal migration to the neck

Thyroid tissue may be found

from the base of the tongue to
the mediastinum

Thyroid
Anomalies

Pyramidal lobe

Lingual thyroid

Sub-sternal/ mediastinal thyroid

Thyroglossal duct cyst

+
Thyroglossal duct cyst
Mid-line mass which
moves with tongue
protrusion
May result to:
1. Secondary infection
2. Compression
3. Fistula
4. Malignancy - 1% (25%
with focus in the
thyroid
gland)
TX:

Sistrunk

+
HYPERTHYROIDISM

thyrotoxicosis - clinical
syndrome caused by
inappropriately high thyroid
hormone action in tissues
generally due to excessive
levels of active thyroid
hormone secreted into the
circulation

hyperthyroidism - a form
of thyrotoxicosis due to
inappropriately high
synthesis and secretion of
thyroid hormone(s) by the
thyroid gland

Excess = thyrotoxicosis

Great majority (>98%) are

due to excess hormones
from the thyroid gland or
exogenous source

Rarely due to excess TRH or

TSH production

Manifestations of hyperthyroidism due to:

increased circulating active thyroid
hormones
increased adrenergic stimulation

+
Causes

1. Primary Thyroid Problem:

Increased production of thyroid
hormone from the gland:
a.Graves' disease (diffuse toxic
goiter)
b. Toxic solitary or multinodular
goiter (Plummer's disease).

+
Causes
2. Extrathyroidal causes:
a. Leak of thyroid hormones

Acute stage of thyroiditis

b.Factitious hyperthyroidism

( exogenous thyroid hormone)

Struma

ovarii

Secondary
TSH

hyperthyroidism

secreting pituitary tumor

+
Diagnostic Tests

+
TSH Assay
Single
In

best screening test for hyperthyroidism

most outpatient clinical situations is the

most sensitive test for detecting mild
(subclinical) thyroid hormone excess or
deficiency.

+
Low TSH

+
RAIU ( N = 5 20%)

+ GRAVES DISEASE

Autoimmune disease

Thyroid receptor antibodies (TRAb)

- thyroid stimulating immunoglobulins (TSI)
- thyroid stimulating antibodies (TSAb)

+
Graves Disease

An autoimmune disorder overstimulation of thyroid

gland by antibodies directed to the thyroid-stimulating
hormone (TSH) receptor on the thyroid follicular cells.

This antibody stimulates iodine uptake, thyroid

hormonogenesis and release, and thyroid gland growth.

TRIAD
Diffusely

enlarged
thyroid gland

Hyperthyroidism

Exophthalmos

+
TSH

T3/T4

Thyroid

autoantibodies

PLUMMERS DISEASE

Toxic nodular goiter

One or more nodules in endemic goiter

becoming hyperfunctioning/
autonomous (TSH- receptor mutations)

Milder symptoms; no extrathyroidal S/Sx

Drugs/RAI Tx - unpredictable result

Surgery is treatment of choice

+
Toxic Multinodular Goiter

Older presentation than Graves' disease.

The thyroid-gland goiters characteristically have one or

more nodules on palpation.

Symptoms such as dysphagia and dyspnea may be present.

Some goiters are retrosternal.

Symptoms are often mild, and atrial fibrillation in the

elderly is frequently the only clinical finding apart from the
goiter.

diagnosis is suggested by the history and physical

examination and confirmed by documenting a suppressed
serum TSH level and raised thyroid hormone level.

Antithyroid antibodies usually are not present.

+
Toxic Multinodular Goiter

Surgery is the treatment of choice

131I ablation may be used in patients who are

unsuitable for surgery, but because has high failure
rate with this treatment

+ THYROID STORM

Seen in unprepared surgical patients

Hyperthyroid pts undergoing nonthyroidal operation

Signs and symptoms of thyrotoxicosis are

magnified

Management

prevention
anti-thyroid drugs
beta-blockers
steroids

Management of Hyperthyroidism
(Graves Disease)

Medical

Radioactive iodine

Surgical

+MEDICAL MANAGEMENT

Euthyroid state is achieved in 4-6 wk

Anti-thyroid drugs- inhibit hormonogenesis within

the thyroid gland.
- propylthiouracil-PTU
- decreases the peripheral conversion of
T4 to T3
- methimazole-Tapazole
- carbimazole-Neo-Mercazole

Beta-blockers- block the beta-adrenergic

peripheral manifestations of the hyperthyroid
state and decreases the peripheral conversion of
T4 to T3
- Propranolol

Medical Treatment

Relapse rate in 12-18 months = 50%

Side effects especially in prolonged use - rashes,

fever, neuritis, agranulocytosis,

Crosses the placenta - fetal goiter

Hypothyroidism

Patient compliance

No morbidity related to surgery

Treatment of choice for small goiters & pregnant

patients (PTU)

RADIOACTIVE IODINE Tx
Standard
Cure

dose - 10 mCi = 8500 cGy

rate is dose dependent

5 mCi - 70%
10 mCi - 87%
15 mCi - 96%

RAI Treatment

Hypothyroidism

15% within 1 year

3% every year thereafter
Permanent

May aggravate exophthalmos - 33%

Exacerbate thyrotoxicosis/thyroid storm

Crosses placenta - no pregnancy for 1 year

May cause infertility in women

May increase risk of cancer in children

Contraindicated in pregnant & breast feeding

patients

Pregnancy test in all women of childbearing AG

RAI Treatment

Ease of treatment

Highly effective esp. in diffuse

goiters

No morbidity related to surgery

Treatment of choice for failed

surgical management

The effect is seen in 1.5 to 4

months

SURGERY

Complete and permanent control of

toxicity

Rapid control of symptoms

Removal of mass

Treatment of choice for huge goiters

Needs pre-operative preparation

Overall morbidity - 1-2%

+
Graves disease - Surgical care
Thyroidectomy:
1. If it is the choice of the patient
2. Second trimester of pregnancy
3. Failure (resistance or intolerance) of
drug therapy
4. Poor compliance to drug therapy

+
Treatment for Graves Disease

+
Contraindications to particular
Tx

+MORBIDITY RELATED TO
SURGERY

Injury to the recurrent and superior

laryngeal nerves

Hypothyroidism

Hypoparathyroidism

Hematoma, seroma

Anesthetic and medical complication

+ NODULAR NON-TOXIC GOITER

Enlargement of
the thyroid

No toxicity

No cancer

CAUSES
FAMILIAL GOITER ENDEMIC GOITER SPORADIC
GOITER
Inherited
enzymatic defect

Iodine deficiency in No definite cause

diet
can be
established

Impaired iodine
metabolism
Usually associated
with
hypothyroidism

Mountainous
regions

+ INDICATIONS FOR

SURGERY

Huge goiter which is

cosmetically
unacceptable

Compression symptoms

Suspicion of malignancy

+ DOMINANT OR SOLITARY
THYROID NODULE

Most are benign - colloid goiter or adenoma

5-15% are malignant: 2-3 fold increase if nodule is

solid

40% incidence in the presence risk factors - low dose

neck irradiation, (+) family history

FNAB - most accurate diagnostic tool

+
Solitary thyroid nodule

+
Factors suggesting increased
risk of malignant potential

History of head and neck irradiation

Family history of medullary thyroid carcinoma (MTC) or multiple

endocrine neoplasia type 2 (MEN2)

Age <20 or >70 years- 50% (<20 y/o)

Male sex-30% (UST)

Growing nodule

Hard consistency- 40% incidence (UP-PGH)

Cervical adenopathy

Fixed nodule

Persistent hoarseness, dysphonia, dysphagia, or dyspnea

+
Laboratory Evaluation

Serum TSH should be tested first, with a

third-generation assay

If TSH level is low (<0.5 micro-IU/mL),

measure free T4 and triiodothyronine (T3);

if TSH level is high (>5.0 micro-IU/mL),

measure free T4 and thyroid peroxidase
antibody (TPOAb)

Serum calcitonin should be measured if FNA

or family history suggests medullary thyroid
carcinoma

+Radionuclide Scanning

Perform thyroid scintigraphy for a thyroid

nodule or MNG if the TSH level is below the
lower limit of the normal range or if ectopic
thyroid tissue or a retrosternal goiter is
suspected

In iodine-deficient areas, perform thyroid

scintigraphy for a thyroid nodule or MNG
even if the TSH level is in the low-normal
range

+
Ultrasound
Benign features

Malignant features

Hyperechoic nodule
Regular margins or halo
Thin wall cyst
Eggshell or amorphous
calcification with shadowing
Polarized colloid(comet or cats
eye)
Multinodularity without a
dominant nodule
Perinodular vascularization on
Doppler
Decreasing size over time

Hypoechoic nodule
Blurred or irregular margin
Invasion of muscle or
surrounding structures
Enlarged cervical nodes
Microcalcifications without
shadowing(real time)
Intranodular vascularization on
Doppler
More tall than wide
(micronodules < 1.5 cm)
Increasing size on TSH
suppression

+
FNA
-cost effective diagnostic tool to differentiate whetehr nodule is
benign or malignant

Cytologic diagnoses should be organized into 4 categories

1. inadequate material
2. benign
3. suspicious
4. malignant tumors

+
FNAC
FNA
B e n ig n
F o llo w u p
1 year
R epeat FN A

S y m p to m s

L o b e c to m y

A t y p ic a l o r S u s p ic io u s

M a lig n a n t

L o b e c to m y

T h y r o id e c t o m y

+Summary of Recommendations for

Management and Treatment of Thyroid

Nodules

Clinical management of thyroid nodules

should be guided by the results of US
evaluation and FNA biopsy

FNA-Positive Thyroid Nodule

For a thyroid nodule with positive
(malignant) FNA results, surgical
treatment is recommended

+
FNA-Negative Thyroid
Nodule

Use of suppressive therapy with levothyroxine (LT4) may

be considered in the following:

Patients from geographic areas with iodine deficiency

Young patients with small thyroid nodules
Nodular goiters with no evidence of functional autonomy
combined with aspiration if nodule is cystic

Use of LT4 therapy should be avoided in most cases and

especially in the following:

Large thyroid nodules and goiters, particularly in the presence

of symptoms or signs of functional autonomy
Clinically suspicious lesions or lesions with an inadequate
cytologic sample
Postmenopausal women and men older than 60 years
Patients with cardiovascular disease

+Facts to remember with suppressive

therapy

LT4 treatment induces a clinically significant reduction of thyroid

nodule volume in only a minority of patients (20-50% success
rate)

Long-term TSH suppression may be associated with bone loss

and arrhythmia in elderly patients and menopausal women

LT4 treatment should never be fully suppressive (exogenous

thyroxine to maintain TSH level at 0.3-3 uU/ml.)

Nodule regrowth is usually observed after cessation of LT4

therapy

If nodule size decreases, LT4 therapy should be continued long

term

If thyroid nodule grows during LT4 treatment, reaspiration and

possibly surgical treatment should be considered

+
Surgical Treatment
1.

Associated local symptoms e.g..

compression

2.

Hyperthyroidism from a large toxic

nodule, or hyperthyroidism and
concomitant MNG

3.

Growth of the nodule

4.

Suspicious or malignant FNA results

5.

Patient belongs to high risk group

Nodule is solid

Failure of thyroid suppression

+
Radioiodine
Indications:
1. For small goiters (volume <100 mL)
2. In those without suspected malignant
potential
3. In patients with a history of previous
thyroidectomy
4. In those at risk for surgical intervention

+
RAI
Not the first-line therapy
1. If compressive symptoms are present
2. If patients have large nodules that
require high amounts of radioiodine
and may be resistant to treatment
3. If immediate resolution of
thyrotoxicosis is desired

+
THYROIDITIS

THYROIDITIS

Hashimotos

De Quervains

Riedels

Acute Suppurative

+
Hashimotos Disease
- Most common form of thyroiditis
- Chronic lymphocytic thyroiditis
-

Autoimmune thyroiditis

Thyroid autoantibodies
1. anti-thyroid peroxidase
2. antithyroglobulin autoantibodies

- Genetic predisposition
- May co-exist w/ papillary CA

+
HASHIMOTOS DISEASE
- Clinical Manifestations:
: Affects women commonly
: Most frequent complaint - enlargement of the neck w/ pain
& tenderness in the
region of the neck
: most individuals are initially hyperthyroid and subsequently
becomes euthyroid or hypothyroid

- diffuse & symmetric enlargement (80%)

HASHIMOTOS DISEASE
-

Diagnostic findings:
Thyroid antibodies

- Treatment
1. Diffuse goiter- LT4 suppression
2. No goiter no therapy
3. Nodular goiter- suppression &/or surgery
4. Surgery - pressure symptoms , suspicion of
malignancy, cosmetic

THYROIDITIS

Generally management is
nonsurgical
- Thyroid hormone replacement for
the hypothyroidism
- Steroids
- Symptomatic relief of pain, fever,
etc.

+ROLE OF SURGERY IN
THYROIDITIS

To relieve compression

If malignancy cannot be ruled out

Cosmetic indication

Incidental finding at surgery

De Quervains

Sub acute thyroiditis

giant cell thyroiditis, is an uncommon, acute

inflammatory disease of the thyroid.

fever, malaise, and unilateral or bilateral thyroid pain

and a recent history of an upper respiratory tract or
viral infection may be given; transient symptoms of
hyperthyroidism

Palpation of the thyroid gland may reveal a tender, firm

gland with mild unilateral or bilateral enlargement.

+
De Quervains

Histologically characterized by an acute inflammatory reaction

of the thyroid gland. Degenerative thyroid follicles are
surrounded by giant cells forming granulomas

Treatment:

NSAIDS for pain relief

For severe cases: Prednisolone 40 mg once daily for 1 to 2 weeks,
followed by a gradual reduction of the dose over the ensuing month

Prognosis

lasts 1 to 6 weeks and resolves spontaneously

Most patients have complete resolution of the disease
10 percent of patients experience permanent hypothyroidism and
require thyroxine replacement therapy.

+
Riedels

marked dense, invasive fibrosis that may extend beyond the

thyroid capsule and involve surrounding structures. Fibrosis
may involve the strap muscles, blood vessels, trachea,
esophagus, and, on occasion, the parathyroid glands, which
leads to hypoparathyroidism.

Severe cases can result in the patient's becoming hypothyroid.

Compressive symptoms: hoarseness, stridor, and dyspnea,

dysphagia may be present

There often is rapid enlargement of the thyroid gland, which

on palpation is woody, hard, and nontender

+
Riedels

resembles anaplastic thyroid cancer, except that the

goiter is smaller

Diagnosis usually is established by FNAC, although

open biopsy occasionally is needed.

Treatment with tamoxifen and steroids often is helpful.

Isthmectomy to relieve compressive symptoms or to
establish the diagnosis is necessary in some patients.

Thyroxine replacement therapy is necessary in

patients with hypothyroidism

+
THYROID CANCER

Incidence: (2005 Philippine Cancer

Facts and Estimates )
9th

most common for both sexes combined

(3.3%), 15th leading site in men ( 1.5%) and
6th among females (5%)

In

2005, estimated 3,521 new cases, 755 in

males and 2,766 in females.

There

will be 1,012 deaths, 245 in males and

767 in females.

+Age and Sex distribution:

( 2005 Philippine Cancer Facts and

Estimates )

Most common cancer of women at ages 15- 24

Incidence among female residents in the Philippines is

among the highest observed worldwide

+
Histologic distribution:
distribution
Well differentiated
type

Papillary

80

%
Follicular cancer
5 10 %
Medullary cancer
59%

Anaplastic type
12%

+
Diagnosis:
History

Exposure to ionizing radiation

( dental x-rays)
Family history
Presence of difficulty swallowing,
breathing, voice changes

Prognostic indices utilized in

thyroid cancer management
Memoria Mayo
l
Clinic,
Hospital 1987

Mayo Clinic, Lahey

Clinic
1993

Karolinska
Institute

GAME AGES MACIS

S

AMES

DAMES

Grade
Age
Metastase
s
Extension
Size

Age
Metastase
s
Extension
Size

DNA
Age
Metastases
Extension
Size

Age
Grade
Extensio
n
Size

Distant
Metastasis
Age
Completeness
of Resection
Invasion
Size

Structural assessment of a
thyroid nodule:

PHYSICAL EXAMINATION

IMAGING TESTS:

ULTRASOUND

CT SCAN

MRI

+
Physical Examination

Complete head and neck

examination
Inspection, palpation of
thyroid gland- note its
size, mobility, consistency,
fixation
Laryngoscopy to
document mobility of the
cords
Palpate for cervical
lymph nodes

+
Diagnosis: Biopsy

Fine needle aspiration Cytology :

- hard mass
- mass associated with neck nodes
suspicious for malignancy
--

+
FNAC
FNA
B e n ig n
F o llo w u p
1 year
R epeat FN A

S y m p to m s

L o b e c to m y

A t y p ic a l o r S u s p ic io u s

M a lig n a n t

L o b e c to m y

T h y r o id e c t o m y

+Functional assessment of a
thyroid nodule:

+
Treatment options

Definition of terms

Total thyroidectomy surgical procedure that removes

entire thyroid gland

Near total thyroidectomy Removal of nearly all of each

thyroid lobe leaving unresected only a small portion of the
gland adjacent to the entrance of the recurrent laryngeal
nerve into the larynx.

Subtotal thyroidectomy removal of most but not all of

each lobe of the thyroid

Hartley Dunhill operation- removal of 1 entire lateral lobe

with isthmus and partial/subtotal removal of opposite lateral
lobe. It is done in non toxic MNG.

+ Total thyroidectomy is recommended

Primary

tumor > 1cm

With risk factors- contralateral nodules,
regional or distant metastases
History of radiation therapy to the head
and neck area
First degree relative with DTC
Age > 45 even if without factors above

+ Advantages of Total Thyroidectomy

Improved survival and recurrence rates

Acceptable rate of complications

1. Bilimoria KY, Extent of surgery affects survival for

papillary thyroid cancer, Ann Surgery.246, 375381(2007)
2. Hay , I et al.Papillary thyroid carcinoma managed at
the Mayo clinic during six decades( 1940-1999):
temporal trends in initial therapy and long term
outcome in 2,444 consecutively treated patients.
World J Surg 26,879-885(2002)
3. Hay ,I et al. Predicting outcome in papillary thyroid
carcinoma:development of a reliable prognostic
scoring systemin a cohort of 1,779 patients
surgically treated at one institutionnduring 1940
through 1989. Surgery 114(1993)

+Papillary thyroid
microcarcinoma(</=10mm)
Argument against aggressive
treatment

Support for Total thyroidectomy

Multifocal disease- 15-43%

Bilateral disease 41%

Cervical node involvement- 1364%

Extrathyroidal tumor extension15-21%

Vascular invasion-3.5%

Distant metastases-1.0-2.8%

10 year survival -100%

Locoregional recurrence
free survival 92%

Distant metastasis-free
survival 97%

+Less than total thyroidectomy reserved

for :

Tumors

< 1 cm ; micropapillary carcinoma;

unifocal, intrathyroidal, low risk
No prior head and neck irradiation
No clinically or radiologically involved
lymph nodes

ATA, 2009

+Management of the
regional nodes

+ Prophylactic vs Therapeutic

prophylactic-

removal of nodes
considered normal pre or intaroperatively (
by palpation or imaging)

therapeutic-

removal of nodes likely to

contain metastatic disease based on
palpation, imaging studies or biopsy.

+ Neck dissection in Thyroid

Cancer

Prophylactic neck dissection not

recommended
If node positive, the most
conservative neck dissection is
warranted

+ Therapeutic Neck Dissection

Central

compartment neck
dissection- for positive
central lymph nodes

Modified

Radical neck
dissection- if with lateral
compartment nodes

Post-op Management

I 131 for ablation of residual normal thyroid

tissue and/ or metastatic disease

Thyroid hormone for suppression for high

risk cancer; replacement for low risk

I 131 whole body scan to detect residual

normal thyroid tissue and/ or metastatic
disease

Follow- up physical exam, serum

thyroglobulin levels, I 131 whole body scans

COMMON HEAD AND NECK

MALIGNANCIES:
An Overview

+Anatomic Sites and subsites

of the Head and Neck

Nasal antrum
Oral cavity

larynx

nasopharynx
oropharynx
hypopharynx
esophagus

+
Oral Cavity

+
Larynx

+
Pharynx

Base of the tongue

Soft palate

uvula

+
Nasal cavity and Paranasal sinuses

Head and
Neck Cancer

Epidemiology

Basics
of
Carcinogenesis
+

Environmental Factors
Inherited factors
Cancer development

Host defenses

Carcinogen exposure

Factors associated with the development of cancer

Etiology and Risk Factors

Chemical
Tobacco
alcohol

Infective
Epstein-barr
virus
Human
papilloma
virus
HIV

Environment
UV rays
Radiation
Wood dust
nickel

Tumor Progression Model in HNSCC

3q amplification

Normal
mucosa

9p
(p 16)

Benign
hyperplasia
or
Alternate
precursor

Dysplasia

3p,
17 p (p53)

Carcinoma
in situ

11q (cyclin D1)

13q (Rb)
14 q (?)

Invasive
cancer

6p
8
4q

Theories on Carcinogenesis

Chemical carcinogenesis

Initiating factor
(SCCA)
Promoting agent:
alcohol
vitamin deficiency
local inflammation

DNA

Carcinoma

Theories on Carcinogenesis

Viral carcinogenesis :

its role is still unclear but suspicious

Evidence of HPV 16 and 18 in SCCA of the paransal

sinuses, nasal cavity & larynx

Elevated antibodies to EBV in NPCA

Natural History of Head & Neck SCCA

Normal stratified squamous epithelium/

Pseudostratified Columnar ciliated epithelium
Initiating &
Promoting agents Leukoplakia
(Hyperplasia/ papillomatosis/Hyperkeratosis)
Pseudoepitheliomatous hyperplasia)

Erythroplakia
(Dysplasia)

Carcinoma in situ

Invasive carcinoma

The Natural History of Cancer

Normal
Cell

Malignant
Cell

Local
Growth

Lymphatic
Capillary
Invasion

Micrometastasis
in RLN

Radiologic
LN Mets

Palpable
LN Mets

Premalignant
Cell

Distant Metastasis

D E AT H

Genetic &/or
Environmental Interactions

Management of
Nodal Metastases

Rationale for Management of Occult

Nodal Metastases

HNSCC are characterized mainly by loco-regional

progression and low risk of distant metastases,
priority is given to loco-regional control

Although the natural history of the primary tumor is

a major consideration, the extent of metastatic
cancer in the cervical nodes determines
locoregional control and survival

AJCC/UICC 2003
Regional Lymph Nodes - N Staging

Rationale for Locoregional Management

Local modalities including surgery and radiotherapy remain

cornerstones of treatment

+Definition of terms

Clinically positive neck- node > 1 cm, spherical rather than flat
ovoid, and harder than nonmetastatic lymph node

Macrometastases- node which can be identified either on PE or by

imaging tests

+Definition of terms

Clinically occult metastases undetected by clinical or radiographic

exam;

Also called subclinical metastases:

Established occult metastases- detected by light microscopy

Occult micrometastases- subpathological or submicroscopic

smaller than 2 mm deposit of malignant cell ;

detected by IHC and/or molecular analysis

Lymphatic Patterns of Flow in Head &

Neck

200 to 350 lymph node in the head and neck

1/3 of total number of nodes in the body

Superficial and deep lymphatic network

+
Superficial lymphatic network

Lie between the skin and superficial fascia

Efferents drain inferiorly along the major veins of the face and
scalp to the common facial vein to the deep cervical nodes

+
Deep lymphatic network
Series

of node that run deep to the

sternocleidomastoid muscle and follow the internal
jugular vein from the base of the skull to the
brachiocephalic junction

Efferents

Two

drain into the venous system at this junction

important group: jugulodigastric and juguloomohyoid nodes

+
Head & Neck Lymphatic drainage

Lymphatic drainage of the head and neck follows a relatively

constant and sequential route.
Rouviere, 1938
Lindberg, 1972

Therefore, it is possible that the first draining lymph node (s) is

also predictive of metastatic spread in SCC of the head and
neck

+
Head & Neck Lymphatic drainage

By knowing the primary tumor site and understanding the

pathways of lymphatic tumor spread, the region of the neck at
highest risk for metastatic disease can be predicted

Probable primary tumor regions in

cervical lymph node metastases

Cervical node
region (level)
according to
Medina (1989)

Localization of lymph
node Metastases

Probable primary tumor regions

Submental nodes
Submandibular nodes

Lips,anterior floor of the mouth

Tongue, palate, cheek

II

Jugulodigastric nodes
Upper jugular nodes
Upper posterior cervical
nodes

Oro-,naso-,hypopharynx,larynx,oral cavity
Larynx,hypopharynx,thyroid
Nasopharynx

III

Mid jugular nodes

Thyroid gland, cervical esophagus

IV

Lower jugular nodes

Supraclavicular nodes

Thyroid gland, cervical esophagus

Lungs,GIT,UGT,Thyroid,breast

Posterior cervical
triangle nodes

Nasopharynx

+Memorial Sloan-Kettering Cancer Center

Leveling System of Cervical Lymph Nodes

First echelon nodes at highest risk for metastases for early

dissemination by metastatic cancer from oral cavity primary lesion

The first echelon lymph nodes at highest risk for metastasis from
primary tumors of the hypopharynx and larynx

The first echelon lymph nodes at highest risk for

metastases from thyroid gland primary

The first echelon lymph nodes at highest risk for metastases

from parotid gland primary

First echelon lymph nodes at highest risk for metastases

from a primay tumor from the submandibular and sublingual glands

+
Head & Neck Lymphatic drainage

However, despite these generalized patterns of drainage,:

There is great variability in the H&N lymphatic flow

This may be due in part to the vast number of lymphatics and

nodes

Also due to anatomical variations between the afferent and

efferent lymphatics in a given node

+
Treatment of Regional Lymphatics

Historical development:

Radical Neck Dissection- Crile, 1906

Modified Neck Dissection- Suarez(1963); Bocca and

Pignataro(1967)

Selective Neck Dissection, Jesse ( 1978)

ELND :
from generalized en bloc resection to focused surgery

+Classical Radical Neck Dissection

Extended Classical RND

+Modified Radical Neck Dissection

MRND Type 1

MRND Type2

MRND Type 3

+
Selective Neck Dissection

oral cavity
Supraomohyoid ND

Extended supraomohyoid ND

thyroid
Central compartment ND

+
Selective Neck Dissection

oro-,hypopharynx
larynx
Jugular(anterolateral)ND

scalp
Posterolateral ND

+Treatment of Regional lymphatics

HNSCC

spreads via lymphatics to the regional nodes

Presence

of lymph node metastases is an important

prognostic factor , decreasing survival by 50% ( Alvi ,
1996)

Early

detection is crucial to treatment planning

PE,MRI,CT

,US are not so reliable in detecting occult

metastases (Woolgar,1995)

Neck

dissection is the only accurate method to stage the

regional nodes (Shah, 1994)

Treatment of the Clinically No Neck

+

Controversy :

Observation

(ELND)

or Elective Neck Dissection

Treatment of the Clinically No Neck

Incidence

Van

of occult metastasis 30%

den Brekel, 1996

Byers, 1988

+Treatment of N0 Neck

Observe:

wait and see approach results in a high proportion of patients

developing metastatic disease

Elective Neck Dissection

Associated morbidity

High proportion of unnecessary surgery

Even if occult metastases are removed, does it confer any survival

advantage?

The N0 Neck

Patients at Risk
High T stage
High grade
Depth of infiltration
Site
Location

+Common Ground

Treatment of the early neck disease carries a better prognosis than

late neck disease

Untreated micrometastases are expected to proliferate gradually

and be detected sooner or later as overt metastases.

Probable
Solution
to
the
Dilemma
+

Selective neck dissection was utilized as a compromise

between observation alone and formal neck dissection

+Rationale for Selective Neck Dissection

There

are defined first echelon nodes at highest risk

of nodal metastases from different primary sites

Therefore,

selective neck dissection is indicated in

patients with high risk of occult metastases.

Some

of these patients develop inoperable neck

metastases and consequent distant metastases
despite close follow up.
Shaha, 2002

Current Philosophy in the Management

of Cervical Lymph Node Metastases
N+

Radical neck dissection for N3 disease and other

select circumstances
MRND XI for N2 and N1 disease
Selective neck dissection for limited N1 disease

N0

Supraomohyoid neck dissection for oral cavity primaries

Jugular node dissection for pharyngolaryngeal primaries

P.O.R.T.

Multiple positive nodes

Extranodal spread
Other ominous features

Indications for Multidisciplinary Treatment

of Squamous Cell Cancers of the
Head and Neck

Higher T stage (III, IV)

Positive margins
Ominous pathologic features

High risk of micromets in N0 neck

Multiple nodal metastases (N2b)

Massive nodal metastases (N3)
Extra nodal spread
Ominous pathologic features

High risk of distant metastases (>T3 or >N1)

Distant metastases

Diagnosis and Management of

Parotid Gland Tumors

Major
salivary
glands
+

Parotid gland
Sublingual
gland

Submandibular
gland

Salivary Gland Tumors

Location

% Malignant

% Benign

Parotid

20 %

70 -80%

Submandibular

40 %

60 %

Sublingual/Minor

60 %

40 %

+
Parotid gland

Parotid
gland
+
Superficial lobe:

lateral to the facial nerve

Makes up 80% of the gland)
Presents as a pre auricular mass;
may also be infra- or post auricular

Deep lobe:

medial to the facial nerve

Makes up the remaining 20%

retromandibular or
parapharyngeal masses, with
displacement of the tonsil or
soft palate appreciated in the
throat.

Facial Nerve Anatomic landmarks:

1. Tragal pointer(1 cm medial and
anteroinferior to the tip)
2. Tympanomastoid suture (68mm medial)
3. Digastric muscle attachment to
groove(superior and on same
plane as muscle attachment)
4. Nerve w/in mastoid bone

?
o
d
u
o
y
d
l
u
o
w
t
Wha

+
Primary

treatment for parotid tumors

is SURGERY !

But

what determines the extent of

surgery?
extent of involvement of the tumor
tumor grade or differentiation
risk of and presence of lymph node
metastasis

+
TREATMENT GOAL

APPROPRIATE MANAGEMENT
BASED ON AN ACCURATE DIAGNOSIS

Controversies in the Management of

+
Parotid Gland Tumors

Rare tumors

Wide variety of histologic types with different biologic behavior

Tendency for delayed recurrence makes it difficult to predict

prognosis

Limited single institution experience

Lack prospective randomized trials

Difficulty

in planning appropriate therapy

What would you do with a patient

presenting with a parotid tumor?

Proceed with surgery based on clinical findings and

intraoperative assessment ?

Or

Do preoperative work up : biopsy and imaging tests?

Diagnosis

Clinical evaluation
Diagnostic Imaging
Preoperative biopsy

+Postgrad Med. 1987 Oct;82(5):105-8, 110-2.

Salivary gland tumors. Diagnostic characteristics
of the common types. Snyderman NL1, Johnson JT.

Information from the history and physical

exam is very important in diagnosis.
Physical examination:

can determine whether a mass is distinct or diffusely enlarged

mobility and skin fixation
depth of the mass and its relationship to other structures
the ductal orifice evaluated for purulence, turbidity, and absence
of salivary flow
Studying the patient's face also provides diagnostic clues

+History

Age

Benign salivary tumors: more common in younger persons

Malignant tumors: more common in the 5th and 6th decades
of life.

+History
How long has the mass been present?

Recent

onset?
(days,weeks)

pain , swelling

Infection

obstruction

Long

duration ?
(months,years) Asymptomatic /symptomatic
Neoplasms

History
+

Rapidity of growth

benign parotid tumor:

asymptomatic mass that
has been present for
months to years
malignant
transformation:
rapid growth in a longstanding pleomorphic
adenoma

+History
continue

with further questions focusing on

local or systemic signs and symptoms, the
presence of swelling or other masses in the
salivary glands, and previous medical
conditions (including skin cancer).

+History

Symptoms suggestive of malignancy

Presence of enlarged cervical node

Presence of facial nerve palsy: suspect malignancy.

Heerfordt syndrome = facial palsy occurring in
association with parotitis and anterior uveitis; often
seen in patients with sarcoidosis.

Pain: more associated with benign conditions, but

also experienced by those with infiltrative malignant
tumors.

Physical
examination
+
Assess consistency

Solid ,firm mass

Cystic, soft mass

Int J Oral Maxillofac Surg. 2012 Jul;41(7):801-6. doi:

10.1016/j.ijom.2011.12.020. Epub 2012 Apr 27 . Signs and
symptoms of parotid gland carcinoma and their
prognostic value.
Stodulski D1, Mikaszewski B, Stankiewicz C.

The most common signs and symptoms were:

parotid mass (96.9%),

pain (40.4%),

enlarged cervical lymph nodes (32.0%)

facial nerve palsy (20.6%)

overlying skin infiltration (19.8%)

In 20% of all cases there were no symptoms of tumor malignancy

The average duration of symptoms suggesting malignancy was 4

months.

+Physical examination

Facial nerve palsy

Cervical lymph node

Induration and
fixation

+Diagnostic Imaging

+Diagnostic imaging
Not

routinely indicated but

may be useful in various
situations

Lesions

bone

Lesions

fixed to adjacent

which appear to
involve parapharyngeal
space,skull base and
vascular structures

+J Oral Maxillofac Surg. 2007 May;65(5):945-52.

Do magnetic resonance imaging and ultrasound add anything
to the preoperative workup of parotid gland tumors?
de Ru JA1, van Leeuwen MS, van Benthem PP, Velthuis BK,
Sie-Go DM, Hordijk GJ.
PURPOSE:
( Level 3 evidence )
To

assess the additional value of magnetic resonance imaging (MRI) and ultrasound
(US) to physical examination (PE) and fine needle aspiration cytology (FNAC) in the
preoperative determination of the location and histology of parotid gland tumors.

PATIENTS AND METHODS:

Prospective

study: 99 patients with 77 benign and 22 malignant lesions ; 82

underwent parotidectomy
MRI

- 89 patients

US - 47 patients

FNAC 88 patients

Data

: tumor characteristics , the presumed diagnosis , the location of the tumor in

relation to the facial nerve was predicted
The

results were compared with the definite histology and the location during
surgery.

+
RESULTS:
1.

MRI characteristics:
incomplete demarcation from normal parotid gland
tissue :
positive predictive value (PPV) for malignancy of 0.48

2. US characteristics:
enlarged lymph nodes : PPV for malignancy of 0.5
3. FNAC : correctly predicted the benign or malignant
nature of the tumor in all cases.
4. P.E : Superficial location was well predicted : PPV of 0.8,
slightly better on MRI (PPV of 0.87), and worse on US (PPV of
0.7).

+
CONCLUSION:

Palpation and MRI are superior to US in predicting

tumor location.

Because the results for palpation and MRI are almost equal,
MRI should only be reserved for specific cases, and not
routinely requested.

Otolaryngol. 2008 Oct;128(10):1152-8.

+Acta
The role of fine-needle aspiration cytology and magnetic
resonance imaging in the management of parotid mass
lesions.
Inohara H1, Akahani S, Yamamoto Y, Hattori K, Tomiyama Y, Tomita Y,
Aozasa K, Kubo T.
( Level 3 evidence)

Retrospective study: 81 subjects ( 60 benign and 21

malignant )

MRI characteristic : unsharp margin and infiltration into

adjacent tissues correlated with malignant histology
Sn : 81% Sp : 92% Accuracy : 89%

FNAC :

Sn : 90%

Sp : 95% Accuracy : 94%

histological typing rate : 80% (benign) 62% (malignant)

Conclusion:

There

is no diagnostic advantage in combining the

two diagnostic tests

Fine-needle

aspiration cytology (FNAC) is the

diagnostic modality of first choice for
characterization of parotid mass lesions, while
magnetic resonance imaging (MRI) should not be
requested routinely.

MRI can be reserved until FNAC shows the indication

for surgical intervention.

+
Summary

Majority of parotid tumors are the benign pleomorphic

adenomas which can be diagnosed on clinical evaluation and
physical exam alone- this should always be the first
diagnostic tool.

Imaging tests such as MRI, CT scan allows evaluation of the

anatomical extent of the cancer an its relationship to the
facial nerve, however these tests should not be routinely
done but may be utilized to evaluate the extent of
involvement.

+Preoperative Biopsy

+
Role Of Fine Needle Aspiration Biopsy in
Salivary Gland Lesions

Controversial

Routine use is not absolutely necessary

Well defined parotid masses are generally treated with surgical

resection whether FNAB indicates benign or malignant disease

The extent of surgery is based on intraoperative findings rather

than FNAB results

FNA may be useful in the ff situations:

Evaluating poorly defined salivary gland masses

Confirming suspicion of malignant disease in order to counsel

patients before surgery

Diagnosing metastatic carcinoma especially with

submandibular gland masses

Distinguishing surgically treatable from nonsurgical pathologic

conditions ( lymphoma)

Evaluating salivary gland masses in patients who are poor

surgical candidates

Diagnostic value of FNA in parotid

+
tumors
Author

Sample size

Sn

Sp

Zbaren
2001

410 parotid
228 with FNA
Retrospective chart
review

64
%

95
%

Cohen,E
.et al.
2004

258 Salivary gland

tumor
169 with surgery
retrospective study

Zbaren
, 2008

110 parotid(68
malignant 42 benign)
Retrospective cross
section

74

Inohara,
2008

82 parotid gland tumors

21 malignant, 60
benign
Retrospective study

Mallon,
DH
2013
Fakhry
N.,
2014

PP
V

Accuracy

(+) LR

(-) LR

86%

12.8

0.38

88

79

6.17*

0.30*

90

95

94

18*

0.11*

Retrospective study 201

parotid cases with FNAC

52

98

78

93

92

26*

0.49*

138 FNAC ,parotid

tumor
30 malignant 108

73

87

61

90

5.61*

0.31*

84

NP
V

77

+Rate of correct diagnosis of histologic type

Rate of correct diagnosis of histologic
type
FNA

FS

BENIGN
(Zbaren, 2008)

27/42 ( 64%)

39/42 ( 93%)

(Inohara,2008)

80%

MALIGNANT
(Zbaren,2008)

49/68 ( 72%)
24/68 ( 35%)

(Inohara,2008)

62%

* Correct diagnosis
(Fakhry,2014)

116/138 ( 84%)

130/138 (94%)

+
SUMMARY

In

general, the sensitivity of FNA is not very high

It

should be interpreted in the context of all other clinical

information
It

has a relatively low specificity in detecting malignancy

FNAC

alone is not prone to determine the surgical

management of parotid malignancies

+Treatment Options

Prognostic factors
Staging
Treatment of the primary
Treatment of the Neck
Adjuvant therapy

+TNM Staging for Salivary GlandCancer

PCS 40th Midyear Convention 9-10May2014 SMX Convention Center

Davao City

PCS 40th Midyear Convention 9-10May2014 SMX Convention Center Davao City

Prognostic Factors
Predicting Outcome

+Overall survival according to site

Shah, 2003

+Survival and histologic type

Shah, 2003

+Survival and histologic grade

Shah, 2003

Malignant Salivary Gland

Tumors
Histologic type

5 yr survival (%)

1.Mucoepidermoid
low grade
intermediate
high
0
2. Adenoid cystic
3. Malignant mixed
4. Acinic cell

92 %
63 %
%
31 % *
50-100 %
76 %

Malignant Epithelial Tumors

Histologic type

Subtypes/
Grade

Biologic behavior

Recurrence
Rate

Mucoepidermoid

Low grade
Intermediate
High

Prolonged course of painless enlargement

Rapid growth w/ pain and ulceration

30% in general

Acinic Cell

Low grade

Tend to recur locally yet seldom

metastasize

Adenoid cystic

High grade

Slow growing,spreads to adjacent tissue

and perineural spaces

Malignant Mixed
tumor

High grade

The extent of invasion (mm) guides

prognosis and behavior

Adenocarcinoma

PLGA
EC
BCA
SDC*

Good prognosis
Behaves as low grade
Low grade
Biologically aggressive

Adenocarcinoma
NOS

Intermediate
High grade

Undifferentiated
carcinoma

High grade

Squamous cell
carcinoma

High grade

DM
Rate

15yr
CR
48%
25%

Tendency to local recurrence and lymph

node metastases

35%

6-16%

55%
10%

10-15%
30-40%
25%

Rare
Rare
10-15%

+Impact

of stage on prognosis

Shah, 2003

Treatment of the primary

+
Salivary Gland Tumors
the discrete mass in the salivary
gland must be considered a
possible malignancy
Excision with clear margins
Superficial parotidectomy
Total parotidectomy

+ Malignant Salivary Gland

Tumors
Treatment approach
modified according to
clinical stage,tumor grade
and histological type

Factors affecting choice of treatment

Extent of the lesion at diagnosis/

clinical stage
Small

(T1, T2)
Extensive local disease
Disseminated disease

- surgery alone
- surgery + RT
- palliative Tx

+Surgery of the primary

A. T1 and T2 (N0)
Low grade - mucoepidermoid, acinic cell, adenocarcinoma

Complete resection
(Superficial lobectomy or Total parotidectomy )

Malignant Salivary Gland

Tumors

B. T1 and T2
High grade - mucoepidermoid, adenocarcinoma,
adenoid cystic,malignant mixed, squamous,
undifferentiated carcinoma

Complete resection by parotidectomy;

Node sampling (N0)
Neck dissection (N+) ;
PORT

Malignant
Salivary
Gland
+
Tumors

C. T3 and T4 ( N0 and N+), any

grade

Total parotidectomy with node sampling

(NO) or total parotidectomy with
comprehensive neck dissection (N+) ;
post-op RT

+ Malignant Parotid Gland

Tumors
Guidelines for facial nerve
management:
1. If clear surgical margins around the
tumor can be obtained, the nerve
should be spared
2. If a dissection plane exists between the
nerve and tumor, large branches of the
nerve are preserved
3. Gross tumor invading the nerve is
resected with nerve sacrifice

Malignant Parotid Gland

Tumors
4. If a margin of normal tissue includes
small,functionally insignificant branches
of the nerve, then these can be

resected
5. Mapping of the branches around the
tumor with a nerve stimulator can be
done to assess areas they innervate in
an attempt to preserve functionally
important branches

+Treatment of the Neck

Incidence of regional lymph node metastasis from

+malignant tumors of salivary glands

Shah, 2003

N= 470 ( 1939-1982)

Spiro, et al. Arch Otolaryngol Head Neck Surg

115;316-321,1989

Incidence of nodal metastases in salivary

+
gland cancer

Clinical cervical metastasis

13 % to 20 %
(Stennert, 2003
Armstrong JG
, 1992
Rodriguez-Cuevas S, 1995
Spiro RH, 1975)

Occult lymph node metastases:

12 % to 48%
(Stennert, 2003
Kelley and Spiro,1996
Armstrong, 1992)

+
Guiding principle

cN+ - perform therapeutic neck dissection

cN- - elective neck dissection is not routinely

recommended; but the neck has to be evaluated/staged/managed
according to the risk for metastasis

+Impact of Nodal disease on prognosis

(Stennert E. 2003)

Overall survival pN- vs pN+ ( 84 % vs 43%)

Disease free survival pN- vs pN+( 83% vs 47%)

Significant correlation of nodal status for overall survival (p<.001) and disease
free survival ( p<.001)

Nodal status is an independent predictor for overall (p=.03) and disease

free survival (p=.001)

+SEER Data 1988-1998

(Bhattacharyya,N. 2002)

Mean survival: (p<.001)

pN0 = 100 months
(95%CI,96-104mos)
pN+ = 59months
(95%CI,54-64mos)

+
Management approach to the N0 neck
Based on the likelihood of occult metastases:
Histologic type
Histologic grade
Size
Clinical predictors

Tumor Histologic type and Occult Lymph

Node Involvement
Histologic Subtype

No. Of Patients (%)

Epidermoid

9/22 (42%)

Adenocarcinoma

7/38 (18%)

Mucoepidermoid

26/179 (14%)

Acinic

2/53 (4%)

Adenoid cystic

2/54 (4%)

Anaplastic

1/1

Malignant Mixed

0/58

Oncocytoma

0/2

TOTAL

47/407 (12%)
Armstrong JG et al, 1992

+Histologic Types and Risk for

Neck Metastases

( Santos, 2001)

Risk Group

Histologic types

Risk for Neck

Metastases, %

Low (<20%)

Adenoid cystic
Low grade MEC
Intermediate MEC

9.1
11.1
16.7

Moderate (20-50%)

Acinic cell
Malignant mixed
Myoepithelial ca
Other

23.1
35
33.3
21.1

High (>50%)

Adenocarcinoma
Undifferentiated
High grade MEC
Squamous cell
Salivary duct ca

54.6
55.6
57.1
78.6
85.7

Univariate p <.001; Multivariate p < .001

Tumor Grade and Occult Lymph Node

Involvement
( Armstrong JG,1992)
Grade

No. (%)

Low

2/125 (2)

Intermediate

13/96(14)

High

29/59(49)

Clinical Factors Predictive of Risk of

occult cervical node metastasis

Author
Year

Grade

HistoTypes

Armstrong
1991

High
grade

SCC>MEC

Frankenthaler
1991

High
grade

Kelly and
Spiro,1996

High
grade

Medina,1998

High
grade

SCC>MEC>
Adenoca

T stage Size

CN7
Age
paraly
sis

Extraglandular ext.

Older

+perilym
phatic inv

>54

+perilym
phatic inv

Other

>4cm

T3/T4

T3/T4

>3 cm

Santos
2001

SDC>SCC> T3/T4
high grade
MEC>undiff>
adenoca

>3cm

Bhattacharyya High
grade
2002

SCC,
adenoca

>5cm

+peri
neural inv

Older
age

Severe
desmo
plasia

+Features of the primary tumor associated

correlates with nodal metastases:
Histologic

cell type high grade

Squamous

cell
Adenocarcinoma
Mucoepidermoid
Undifferentiated
Primary

tumor size >4 cm- T3 lesions

Extraglandular

extension

If the likelihood of regional nodal disease

could be predicted, concurrent neck
dissection can be planned at the time of
resection of the primary

Why
is
there
a
need
to
electively
treat
+
the cNO neck?

Informative for nodal staging

Need for post-operative radiation

Regional control is improved when removing occult nodal disease

Neck disease progresses unpredictably

Observed N0 may progress directly to N2 or N3

The outcome is poor after neck recurrence

Salvage rate is 12-30%

+
Recommendations:
Elective

neck dissection for the ff

high risk histologic types:
High

grade mucoepidermoid carcinoma

Malignant mixed tumor
Salivary duct carcinoma
Squamous cell carcinoma
Undifferentiated carcinoma
Adenosquamous carcinoma
Ferlito A, Shah A et al, 2001

Elective treatment of the neck in patients with either high

grade tumors of any size or low grade tumors > 4 cm

Armstrong JG. ,HarrisonLB,Thaler HT.The indication for

elective treatment of the neck in cancer of the major salivary
glands. Cancer 69:615-619, 1992

+
Surgical Options

Advantages of elective conservative neck

dissection

The

procedure could be performed through the same

surgical incision

Minimal

morbidity

A negative

nodal examination permits treatment with post

op RT to be limited to the primary site without including the
neck- results in less radiation fibrosis,edema, mucositis

Advantages of elective conservative neck

+
dissection

The

procedure could be performed

through the same surgical incision

Minimal
A

morbidity

negative nodal examination permits

treatment with post op RT to be limited to
the primary site without including the
neck- results in less radiation
fibrosis,edema, mucositis

Summary
:Tx
of
cNO
+

Elective/ selective neck dissection at the time of surgery is of value in

the treatment of high grade salivary gland cancer and T3/T4 lesions

Utilization of FS , if available, would permit conversion to a

comprehensive neck dissection

If occult metastatic disease is identified in final histopath, this would

give prognostic information and guide further treatment

If postoperative RT is indicated preoperatively, END is not necessary

+Role of Radiotherapy

+
Radiation Therapy as an Option

Elective irradiation is an adequate treatment for cN0 neck

with high risk tumors

Frankenthaler RA. Arch Otolaryngol Head Neck Surg

1993;119:517-520

+Impact

of adjuvant PORT

+Armstrong JG, et al. Malignant tumors of major salivary gland origin:Matched

pair analysis of the role of combined surgery and postop radiotherapy. Arch
Otolaryngol Head Neck Surg 116 :291-293,1990

Surgery Alone
(1939-1965)

Surgery +
PORT
(1966-1982)

Stage I, II

96%

82%(NS)

Stage III, IV

10%

51%(p=.015)

5yr survival

+Recommendations regarding RT

Combined neck dissection and radiation may reduce neck

recurrences and may be indicated for selected patients,
particularly if multiple metastatic nodes are present

+
Indications for post op RT

T3- T4 tumors

Close or positive margins/incomplete resection

Bone involvement

Perineural tumor

Documented lymph node metastases

Recurrent disease

+
SUMMARY

Recent studies in the diagnosis and treatment of parotid

cancer were reviewed.

Modern imaging allows evaluation of the anatomical extent

of the cancer and its relationship to the facial nerve as an
aid to physical exam

Use and interpretation of preoperative biopsies should be

taken in the presence of other clinical information

Summary
+

Surgery remains the treatment of choice with preservation

of a functioning facial nerve.

Resection of the facial nerve should only be undertaken

when there is clinical evidence of nerve dysfunction.

The NO neck should be treated in advanced-stage and highgrade cancers, but the choice between elective surgery and
elective irradiation remains controversial.

Low-stage, low-grade tumors can generally be cured by

surgery alone.

Postoperative radiotherapy improves locoregional control in

all other tumor stages and grades.

PCS 40th Midyear Convention 9-10May2014 SMX Convention Center

Davao City

Thank You

+
Acknowledgement

Prof. Jatin Shah, MSKCC

Menarini Philippines