CC

56 year old male

comes to your
office saying that
last week he
noticed a lump in
the right side of his
neck, and wants to
know what that
meant. He has no
symptoms.
1Next?

HPI
None. No pain, no other complaints, no earlier
findings.

2Next?

PMH
LIH repair 5 years ago.
Had a normal colonoscopy at 52

3Next?

ROS
NC

4.OK, what SHOULD you write?

ROS

Constitutional: No complaints
Eyes: No complaints
ENT: No complaints
Cardiovascular: No complaints
Respiratory: No complaints
Gastrointestinal: No complaints
Genitourinary: No complaints
Musculoskeletal: No complaints
Integumentary: Has this lump in his right neck
Neurological: No complaints
Psychiatric: No complaints
Hematologic: No complaints
Allergic/Immunologic: No complaints
5.Next?

MED/ALL
A baby ASA a day
No allergies

6Next?

SH/FH
Smokes 25 pk/yrs since the age of 18 years, drinks
socially, meaning at gatherings, parties, weekends,
nights.
FH: wife healthy, two healthy grown children, parents:
Father died at 86 of pneumonia, mother alive at 78,
healthy

7Any comments?
8Next?

PE
Normal except neck exam: a 2x2 cm soft, movable mass is located above the clavicle, medial to the SCM
muscle.

Vital Signs: T 97.4 HR 56 bpm BP 132/78 O2 sat 96%RA RR 16

GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute
distress.
HEAD: Normocephalic.
EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
NOSE: No nasal discharge.
EARS: External auditory canals and tympanic membranes clear, hearing grossly intact.
THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in
good general condition.
NECK: Neck supple, non-tender. 2x2 cm mass medial to the R SCM, movable. No thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis
or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits.
LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
MUSKULOSKELETAL: ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular
development. Normal gait.
EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities,
normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness,
swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips
reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus,
weakness or deformity.
NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+
throughout. Cerebellar testing normal.
PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The
patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or
abnormal behaviors during the examination. Patient is not suicidal. 9Now what?

Now what?
How about an FNA?

Now what?
FNA of neck mass showed moderately
differentiated invasive SCC

10.What is SCC? 11.Any markers?

What is SCC?
Head and neck SCC is a cancer that starts in the lip, oral
cavity, nasal cavity, paranasal sinuses, pharynx, and larynx
SCC originates from the squamous mucosa or from ciliated
respiratory epithelium that has undergone squamous
metaplasia
HNSCCs express epithelial markers such as cytokeratins. In
well-differentiated tumors, no additional stains are usually
needed. In poorly-differentiated lesions,
immunohistochemistry may be useful. HNSCCs are
immunopositive for cytokeratin cocktails, AE1/AE3 and
pancytokeratin. CK5/CK6 and p63 are also excellent
markers to detect squamous differentiation.
11Any histological features typical of SCC?

This is a welldifferentiated,
keratinizing
squamous cell
carcinoma of the
oral cavity at
medium
magnification. The
pinker or more
eosinophilic areas
are keratin whorls
or pearls.
12How do we
work this up?

PET-CT
2.9 cm right level 2 LN w/ intense uptake and SUV max
of 12.9
Second 8mm node adjacent
Subtle asymmetric uptake in R posterior BOT (base of
the tongue, a normal variation) potential uptake in
right tonsil

No mass on CT/enhanced CT

13Whats an SUV?

Whats an SUV? (no, its not some sort of

car)
Cancerous cells multiply more rapidly than
normal cells, so they are more active. A positron
emission tomography (PET) scan creates images
of cell activity, using standardized uptake
value (SUV) as a measurement. SUV describes
the level of activity in a particular spot compared
to activity elsewhere in the body. An SUV reading
of 1 is baseline or normal cellular activity. An SUV
of 2.5 or greater can indicate metastatic cancer
activity, but other factors can provoke abovenormal readings.

Right inferior
internal jugular
node
metastases
with extranodal
invasion.
PET scan 64
minutes after
fludeoxyglucos
e (18F) was
administered,
shows some
fluff around the
tumor.

STAGING SCC of the Head and Neck

Patient Staging:
T0:No tumor
LN: N2b multiple ipsilateral LN, none more than 6
cm
Metastases: M0 none

14What does this mean?

 Primary tumor (T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor 2 cm or less in greatest dimension

T2 Tumor > 2 cm but not more than 4 cm in greatest dimension

T3 Tumor > 4 cm in greatest dimension
T4a Moderately advanced local disease
Lip - Tumor invades through cortical bone, inferior alveolar nerve, floor
of mouth, or skin of face

Oral cavity - Tumor invades adjacent structures (eg, through cortical

bone into deep extrinsic muscle of the tongue, maxillary sinus, or skin of
face)

T4b Very advanced local disease

Tumor invades masticator space, pterygoid plates, or skull base and/or
encases internal carotid artery

 Regional lymph nodes (N)

NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node 3 cm or less in greatest
dimension

N2 Metastasis in a single ipsilateral lymph node > 3 cm but not

more than 6 cm in greatest dimension; or in multiple ipsilateral
lymph nodes, none > 6 cm in greatest dimension; or in bilateral or
contralateral lymph nodes, none > 6 cm in greatest dimension
N2a Metastasis in a single ipsilateral lymph node > 3 cm but not
more than 6 cm in greatest dimension

N2b Metastasis in multiple ipsilateral lymph

nodes, none > 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none > 6
cm in greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest dimension
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
15.Prognosis?

Prognosis of HNSCC
There are two prognostic factors for HNSCC: HPV
(Human Papilloma Virus) positivity and exposure to
tobacco and alcohol
HPV is one of the most important independent
favorable prognostic factors in HNSCC. However, only
the rate of locoregional recurrence, but not that of
distant disease, is diminished in patients with HPVpositive SCC.
Increased sensitivity to chemotherapy and
radiotherapy in HPV-positive oropharyngeal cancer may
be related to absence of exposure to tobacco and
presence of functional p53 protein.
Increased survival of patients with HPV-positive SCC
may be in part attributable to absence of dysplastic
fields related to tobacco and alcohol exposure.

Prognosis of HNSCC
It has been demonstrated that the presence and
type of TP53 mutation is also of prognostic
relevance.
Several studies have shown a correlation between
p53 mutation and lower response rates to
chemotherapy and shorter overall survival times.

Prognosis of HNSCC
About one third of patients presents with early-stage
disease, whereas two thirds present with advanced
cancer with lymph node metastases.
Early-stage tumors are treated with surgery or
radiotherapy and have a favorable prognosis.
The standard of care for advanced tumors is surgery
combined with adjuvant radiation therapy and/or
chemotherapy.
Survival outcomes are poor (40-50% five-year survival
rates) and the treatment is uniformly morbid.
Organ-preservation protocols, with combined
chemotherapy/radiation therapy and surgery for salvage,
are increasingly performed. 16What should our patient
have first? Surgery? What surgery? Radiation? Chemo?

Our patients Surgical Treatment

Direct Laryngoscopy with biopsy 17.Whats this?

Percutaneous Gastrostomy 18.Whats this?
Extraction of 4 wisdom teeth 19. Why?
Trans-oral Robotic Radical Tonsillectomy 20.Whats
this?
L and R Node Dissection, R 1-4, L 1 21.Whats this?
R Submandibular gland transfer (to keep gland out
of future radiation field) 22. Whats this?

23Anything else?

Lymph nodes of the Head and Neck

Level IA submental nodes
Level IB submandibular nodes
Levels IIA and IIB upper jugular nodes along SCM to the
inferior border of the hyoid bone above and below spinal
accessory nerve. IIA: drains oral cavity and larynx. IIB:
drains oropharynx
Level III middle jugular nodes to the inferior border of the
cricoid cartilage. Drain oral cavity, oropharynx,
nasopharynx, hypopharynx, and larynx.
Level IV lower jugular nodes to the clavicle. Drain
hypopharynx, thyroid, cervical esophagus, and larynx.
Levels V A and B posterior triangle nodes. Drain
nasopharynx, oropharynx, and the skin of the posterior
scalp and neck
Level VI anterior compartment. Drain thyroid gland,
glottic and subglottic larynx, apex of the pyriform sinus,
and the cervical esophagus

Future Treatment
Awaiting radiation therapy (5 weeks after surgery)

Surgical Therapy
Panendoscopy is the primary surgical therapy used to
discover an occult primary lesion. The procedure
begins with nasal endoscopy using a 0 rigid
endoscope to examine the nasopharynx. Generous
biopsy samples of the nasopharynx are obtained for
both frozen sectioning and permanent sectioning.
Frozen sectioning of the nasopharynx is the first
portion of the endoscopy.
If the results are positive for carcinoma, the procedure
is halted because definitive treatment of
nasopharyngeal carcinoma is radiation and
chemotherapy. By performing this aspect of the
procedure first and by obtaining results that are
positive, the patient is spared both the additional
morbidity of alternate biopsies of the site and the
probable surgical treatment of the cervical
lymphadenopathy.

Surgical Therapy
If the results from the frozen sections of the
nasopharynx are negative, the oral cavity, oropharynx,
hypopharynx, and larynx are inspected and palpated.
These areas can be evaluated with a laryngoscope.
After thoroughly palpating the base of the tongue, the
examiner obtains biopsy samples. The tonsillar fossa is
then inspected. Considerable controversy surrounds the
proper sampling technique of a tonsil. Some clinicians
obtain biopsy samples of any suspicious sites found on
the tonsil. Others perform elective tonsillectomy to
eliminate sampling errors. The unilateral tonsillectomy
adds little morbidity and allows thorough sampling of
this site. Others argue that bilateral tonsillectomy also
adds little morbidity and decreases confusion of
asymmetric tonsils in follow-up examination. The only
clinical situation that apparently justifies a bilateral
tonsillectomy is the presence of bilateral metastatic
cervical lymphadenopathy.

Surgical Therapy
Next, a cervical esophagoscopy is performed to
examine the esophagus. If any suspicious lesions
are present, biopsy samples are obtained and
sent for permanent sectioning.
Depending on the results of the panendoscopy,
either the newly found primary lesion (other than
the nasopharynx) is addressed surgically along
with the cervical lymphadenopathy or the
lymphadenopathy is addressed separately with
the appropriate neck dissection.

Radiation Therapy
The entire pharyngeal axis is generally accepted
as the mucosal sites to be included in the
radiation field in patients with occult primary
lesions. Theoretically, this should prevent the
occurrence of the primary lesion. In order to
decrease the morbidity of radiation induced
xerostomia, some practitioners would not include
the nasopharynx within the radiation field if the
results of the endoscopy and the findings on
imaging studies are negative

Radiation Therapy
Although the value of radiation therapy has been
confirmed, the field to be covered by the
radiation therapy is controversial.
Bilateral neck irradiation?
Unilateral neck irradiation?
Bilateral cervical irradiation with surgical therapy
improves locoregional control of cancer and is
accepted as the standard of care for patients with
advanced cervical disease (>N2).

Chemotherapy for Squamous cell carcinoma

Chemotherapy is generally reserved for patients
with clinical or pathologic indicators of aggressive
disease or primary nasopharyngeal carcinoma.
Patients with extensive lymphadenopathy
(>N2C), pathologic evidence of extracapsular
spread of the carcinoma outside of individual
lymph nodes, unresectable local disease, or
distant metastatic spread of the carcinoma often
undergo chemotherapy for curative intent or
palliative treatment.

Chemotherapy for Squamous cell carcinoma

Treatments that include platinum-based chemotherapy
are used in patients with squamous cell carcinoma.
The most commonly used chemotherapeutic agents
are 5-FU and cisplatin. Alternatively, docetaxel has
also been used in combination with cisplatin.
Paclitaxel 175 mg/m2IV infusion over 3h on day
1pluscisplatin 100 mg/m2IV on day 2plus5-FU(5fluorouracil) 500 mg/m2/day IV continuous infusion
over 120h every 21dor
Docetaxel 75 mg/m2IV on day 1pluscisplatin 75
mg/m2IV on day 1plus5-FU 750 mg/m2/day IV
continuous infusion on days 1-5; every 21d

Concomitant Radiation and Chemotherapy

Aggressive medical management consisting of
both chemotherapy and radiation is reserved for
advanced disease in patients who are deemed
poor candidates for surgery, inoperable, or
palliation.
Concurrent chemoradiotherapy of N2 and N3
nodal disease from an unknown primary was able
to give patients a 5-year survival rate and control
rate of 75% and 87%, respectively.
Also, patients with nasopharyngeal carcinoma are
treated with combined chemoradiation therapy
without surgery.

Monoclonal Antibody Chemotherapy

Recently, the use of targeted drugs has entered
the field. Cetuximab is one of the most well
studied monoclonal antibodies directed against
EGFR. Binding of the antibody to EGFR prevents
activation of the receptor by endogenous ligands.
An overall survival benefit and an increased
duration of locoregional control have been
observed in advanced HNSCCs treated with a
combination of radiation therapy and cetuximab,
compared to radiation therapy alone.