oral cavity and oropharyngeal cancer · 2016-08-23 · oral cavity and oropharyngeal cancer wendy...

Oral Cavity and Oropharyngeal Cancer

Wendy R. K. Smoker, MS, MD, FACR

Professor Emeritus-Neuroradiology

University of Iowa Hospitals and Clinics

I have no relevant financial relationships with commercial interests

NEXT 25 MINUTES

ABSOLUTELYNOTHING!

Learn common pathways of “spread” of oropharyngeal and oral cavity SCCa.

Educational Objectives

Learn the most common sites of oropharyngeal and oral cavity SCCa.

Review common nodal drainage patterns of oropharyngeal and oral cavity SCCa.

Recognize features that upstage primary tumors to T4a (moderately advanced) and T4b (very advanced) local disease.

Stage 0: Tis N0 M0Stage I: T1 N0 M0Stage II: T2 N0 M0Stage III: T3

T1-3N0N1

M0M0

Stage IVA: T4aT1-4a

N0-1N2

M0M0

Stage IVB: T4bAny T

Any NN3

M0M0

Stage IVC: Any T Any N M1

N1: Single ipsilateral node <= 3 cmN2a: 3 cm < Single ipsilateral node <= 6 cmN2b: Multiple ipsilateral nodes <= 6 cmN2c: Bi- or contralateral node(s) <= 6 cmN3: Node > 6 cm

T1: Tumor <= 2 cmT2: 2 cm < Tumor <= 4 cmT3: Tumor > 4 cm or extension to lingual surface of epiglottisT4a: Moderately advanced local disease: Involvement of larynx, extrinsic tongue

muscles, medial pterygoid, hard palate, or mandibleT4b: Very advanced local disease: Involvement of lateral pterygoid, pterygoid plates,

lateral NP, BOS, or carotid artery encasement

Oropharyngeal Carcinoma Staging (Tonsil and Base of Tongue)

Size MATTERS

AJCC, 7th edition

Tonsillar SCCa: What to Report

• Tumor size?

• Involvement of structures/spaces that will upstage the primary tumor:

• T4a: Larynx, ext tongue mm*, med pterygoid m, hard palate, mandible

• T4b: Lat pterygoid m, pterygoid plates, lateral NPhx, BOS, ICA (CS)

• What is the status of regional lymph nodes(58-76%)? Levels I-V

• Also should report involvement of soft palate, base of tongue, oral tongue…

Radiology 205:629-646, 1997

Mucosa over ATP (palatoglossus m): most common site of OP SCCa

*Genioglossus, hyoglossus, palatoglossus, styloglossus

Size? Larynx? SPal/HPal? NPhx? BOT/OT? MandExt mm?CS?MS?Nodes?

3 cmNY-SPalNNNNNNY-IIa

MD Tonsillar SCCa (p16+)64M: Globus discomfort in posterior throat

T2N1M0=III SUV = 13.3

Size? Larynx? SPal/HPal? NPhx? BOT/OT? Mand? Ext mm?CS?MS?Nodes?T2N2cM0=IVA

3 cmNNNNNNNNY-Bilat

MD Tonsillar SCCa61M: Bilateral enlarging neck masses

51M: Rt neck swelling, oral cavity “sore”, 15 lb wt loss in 2 months

Size?Larynx? SPal/HPal?NPhx?BOT/OT?Mand?Ext mm?CS?MS?Nodes?

2.5 cmNY-SPalNY-BOTNYNNY-3.2cm

PD Tonsillar SCCa (p16+)

Ulceration

Nl hyoglossus

T4a (ext mm) N2a (3.2 cm) M0 = IVASUV = 16.0 SUV = 17.0

Size? Larynx? SPal/HPal?NPhx?BOT/OT?Mand?Ext mm?CS?PPS?MS?Nodes?

T4b (lat NPx) N1M0=IVB

4.7 cmNY-SPalYNNNNNNY-IIA

MD Tonsillar SCCa

Size? Larynx? SPal/HPal?NPhx?BOT/OT?Mand?Ext mm?CS?PPS?MS?Nodes?

5.5 cmNY-SPalYNNNNNNY-IIA, RPS

PD Tonsillar SCCa (p16+)

T4b (lat NPhx) N2cM0=IVB

43M: Pain, trouble swallowing, voice changes, and otalgia

Also had PD SCCa in Rt tonsil

BOT Carcinoma-What to Report• Tumor size?

• Extension across the midline?

• Involvement of structures/spaces that will upstage the primary tumor: T4a: Larynx, ext tongue mm, med pterygoid m, hard palate, mandible

T4b: Lat pterygoid m, pterygoid plates, lateral NPhx, BOS, ICA (CS)

• What is the status of regional nodes (50-83%)? Levels II-V

• Should also report extension to oral tongue, FOM, SLS, tonsil/soft palate along GTS…

Radiology 205:629-646, 1997 T2N1M0=III

Size? Xs midline?Tonsil?SPal/HPal? OT? Ext mm?FOM/SLSLarynx?CS?MS?Nodes?

3.5 cmNYNNNNNNNY-IIA

This case is included to show extension to the ant tonsillar pillar via the glossotonsillar

sulcus on PET

BOT Carcinoma

T4a (ext mm) N1=IVA

Size? Xs midline?Tonsil? SPal/HPal? OT? Ext mm?FOM/SLS?Larynx?CS?MS?Nodes?

Ulceration

Ulceration

Normal mylohyoid m

Normal mylohyoid m

Normal hyoglossus m

3.5 cmNYNNY*Y-FOMNNNY-IIA

BOT Carcinoma

T4a (ext mm) N0M0=IVA

Size? Xs midline?Tonsil? SPal/HPal? OT? Ext mm?FOM/SLSLarynx?CS?MS?Nodes?

4.3 cmYYY-SPalYY*YNNNN

BOT Carcinoma

Hyoglossus

Genioglossus

SUV = 10.5

55F: 50 lb wt. loss, dysphagia, odynophagia, trismus, Rt otalgia, Rttongue deviation, and dysarthria

Size? Xs midline?Tonsil? SPal/HPal? OT? Ext mm?FOM/SLSLarynx?CS?MS?Nodes?

4.2 cmNYNNNNY?YY (MP)Y*

PD BOT Carcinoma (p16+)

T4b (CS involvement) N2bM0=IVB

*Conglomerate nodal mass

Oral Cavity Carcinoma Staging• TX: Primary tumor (T) cannot be assessed• T0: No evidence of primary tumor• Tis: Carcinoma in situ • T1: >/= 2 cm in greatest dimension• T2: Tumor 2 to 4 cm• T3: Tumor more than 4 cm• T4a: Moderately advanced local disease (more

than superficial erosion)Lip: Invades through cortical bone,

inferior alveolar nerve (PNT), FOM, skin of face (chin or nose).

Oral cavity: Invades adjacent structures only (e.g. through cortical bone into deep (extrinsic) tongue muscles, maxillary sinus, or skin of face)

• T4b: Very advanced local disease. Invades the masticator space, pterygoid plates, skull base and/or encases the ICA.

• NX: Regional Lymph nodes cannot be assessed

• N0: No nodes• N1: Single, ipsilateral, < 3cm• N2a: Single, ipsilateral, 3 to 6 cm• N2b: Multiple ipsilateral, < 6 cm• N2c: Bilateral or contralateral, < 6 cm• N3: > 6 cm

• Stage 0: Tis, N0, M0• Stage I: T1, N0, M0 • Stage II: T2, N0, M0 • Stage III: T3, N0, M0

T1, N1, M0T2, N1, M0T3, N1, M0

• Stage IVA: T4a, N0, M0 T4a, N1, M0T1, N2, M0T2, N2, M0T3, N2, M0T4a, N2, M0

• Stage IVB: T4b, any N, M0Any T, N3, M0

• Stage IVC: Any T, Any N, M1

AJCC, 7th edition

NODES

Oral Cavity Carcinoma Sites

• Lower lip 38 %• Oral tongue 22 %• Floor of the mouth 17 %

• Gingiva/RMT * 6 %• Hard Palate 5 %• Upper lip 4 %• Buccal mucosa 2 %• Other 5.5 %

* Includes retromolar trigone Ca because natural history, anatomic relationships, and management are closer to lesions of the gingiva than anterior tonsillar pillar

Lower Lip Carcinoma-What to Report

• Size?

• T4a: Skin of face, cortical bone (mand), FOM involved, *Perineuraltumor spread (PNTS): mental n inferior alveolar n V3?

• T4b: MS, ptery plates, BOS, ICA

• Intracranial extension (ICRAN ext)?

• Lymph nodes? Levels I and IIRadiology 205:629-646, 1997

Although it is the most common site for SCCa (38%), these lesions rarely require imaging evaluation.

T1N2bM0=IVA(very small primary tumor but already stage IVA due to nodal

disease)

Size?Skin?Mand?PNTS?FOM ext?MS ext?ICRAN ext?Nodes?

1.5cmNNNNNNY-IB/IIA

Lower Lip Carcinoma

Size?Skin?Mand?FOM ext?PNTS?MS ext?ICRAN ext?Nodes?

3cmNYNY*YNN (9mm)

T4a (PNTS-Inf Alv n) N0M0=IVA

WD Lower Lip Carcinoma 80F: Rock hard lip mass and Rt chin numbness

Fat in normal Inf Alv Canal

Lower Lip Carcinoma

Courtesy M Michel, MD

Size?Skin?Mand?FOM ext?PNTS?MS ext?ICRAN ext?Nodes?

>4cm!YYYYYY-V3N

T4bN0M0=IVB

Tumor exiting Inferior Alv canal



Oral Tongue Carcinoma

• Relationship to midline fibrofatty septum. Clear surgical margin if tumor abuts or crosses the midline would not be possible without total glossectomy which is functionally crippling. These patients usually undergo non-surgical management.

• Relationship to the sublingual space where the neurovascular bundle (NVB) of the tongue is located. Sacrifice of one NVB with tumor but leave a small pedicle attached to the contralateral NVB. However, if both NVBs are involved, the situation remains as above for contralateral disease.

Two most important findings in relation to the primary tumor that impact treatment and prognosis are:

Oral Tongue Carcinoma-What to Report

Radiology 205:629-646, 1997

• Tumor size? • Midline crossed (X ML)?• T4a: Cortical bone (mand), extrinsic

tongue muscles (Ext mm), FOM/SLS, skin of face

• T4b: MS, ptery plates, BOS, ICA (CS)

• Nodal involvement? (34%-65%) Levels I-III

• Should also assess extension to BOT, tonsil and soft palate

67F: Rt tongue soreness, Rt. otalgiaSize?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?

2.5cmNNYYNNNN

Nl mylohyoid m

Nl SLS

PD Oral Tongue Carcinoma

T2N0M0=II

Size?X ML?Ext mm?FOM ext?SLS?Mand?BOT?Tonsil?Nodes?

60M: Rt tongue “ulcer” x 2 months

MD Oral Tongue Carcinoma (p16+)

4.0cmYNNNNNNN

T3N0M0=III

32F: Painful tongue ulceration x 3 yrs; 40lb weight loss; new otalgia


5.5cmYYYYNYNY-IIA

MD Oral Tongue Carcinoma


Genioglossus


5 cmAbutsYYYNYNY-IIA

Nl mylohyoid m

Nl mylohyoid m

Oral Tongue Carcinoma


Nl SLS


6.8 cmAbutsYYYNYYN

MD Oral Tongue SCCa60F: Left tongue pain and otalgia x 6 months

Nl hyoglossus

?

?

1/2 T4a (ext mm) N0M0=IVA??

2/2

Now see involvment of:Mast Space Lat pterygoid musclePPF/V2V3 in f ovale

Stage IVB

• Tumor size? • Midline crossed (X ML)?• T4a: Cortical bone (mand), oral

tongue (OT), extrinsic tongue muscles (Ext mm), SLS, skin of face

• T4b: MS, ptery plates, BOS, ICA (CS)

• Nodal involvement? (30%-59%) Levels I-II

Floor of Mouth Carcinoma-What to Report

Radiology 205:629-646, 1997

One of the earliest findings of SLS involvement by these tumors may be submandibular duct obstruction!

49M; FOM tenderness; 1/5 vodka/day,100 pack years

Size?SLS?X ML?Mand?Oral tongue?Ext mm?BOT?Tonsil?Nodes?

2.5.cmY-RtYNNNNNN

Dilated Wharton duct


T2N0M0=II

Floor of Mouth Carcinoma

T2N1M0=III

Nl SLS Nl SLS Size?SLS?X ML?Mand?Oral tongue?Ext mm?BOT?Tonsil?Nodes?

2.5.cmY-RtNNNNNNY-IB



*Cortical mandibular erosion

Size?SLS?X ML?Mand?Oral tongue?Ext mm?BOT?Tonsil?Nodes?

3.5cmYAbutsY*YYNNN

Nl SLS




The Pterygomandibular Raphe (PMR)

• Thickening of the buccopharyngeal fascia

• Gives origin to the buccinatorand superior constrictor muscles

• Extends from hamulus of the med ptery plate to posterior aspect of the mylohyoid line

• A potential pathway for disease spread from OC & OP to BS, MS, NP, FOM…

• Extension alongpterygomandibular raphe(Buccinator or superior constrictor muscles)??

• Extension to masticator space (MS), maxilla, base of skull (BOS)?

• Extension to floor of mouth (FOM), mandible (mand)?

• PNTS?

• Nodes involved? (39%-56%) Levels I-III

Retromolar Trigone Carcinoma-What to Report

Radiology 205:629-646, 1997

T1N1M0=III

63M: Unknown SCCa primary (neck node)Size? Bucc m?SPC m?MS ext?Maxilla?BOS?Mand?PNTS?FOM?Nodes?

1.5cmNNNNNNNNY-IIB

RMT Carcinoma

T4a (MS) N0M0=IVA

Normal buccinator m

Normal SPC m

RMT Carcinoma

Size? Bucc m?SPC m?MS ext?Maxilla?BOS?Mand?PNTS?FOM?Nodes?

1.5cmYYYNNNNNN

T4a (*) N0M0=IVA

Size? Bucc m?SPC m?MS ext?Maxilla?BOS?Mand?PNTS?FOM?Nodes?

>4 cmYNYY*NY*Y*NN

Dilated Stenson duct

Normal buccinator m

Normal mandibular marrow

*Tumor extends along PMR with PNTS into inferior alveolar canal

RMT Carcinoma

oral cavity and oropharyngeal cancer · 2016-08-23 · oral cavity and oropharyngeal cancer wendy...

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