Tumorile capului & gtului

10/4/2013

NG2005

Tumorile ORL
I. Generaliti
1. Epidemiologie
2. Etiologie 3. Istorie natural

4. Prezentare clinic
5. Principii de stadializare & tratament

II. Localizri anatomice III. Principii & rezultate terapeutice, 10/4/2013 urmrire NG2005

Tumorile ORL: Generaliti (1)

1. Epidemiologie inciden: cca 10% din totalul TM Romnia mortalitate: cca 3-5%, B>F B>F = 10:1; tendin de apropiere! vrst: 45-70 ani, cu particulariti: RF: aduli tineri
10/4/2013 NG2005 localizare: laringe, cavitate bucal, RF, OF 3

Tumorile ORL: Generaliti (2)

1. Epidemiologie (2) particulariti geografice: India: cavitate bucal China, Africa de Nord: rinofaringe

10/4/2013

NG2005

Tumorile ORL: Generaliti (3)

2. Etiologie

fumat, alcool
igien bucal defectuoas

factori de mediu: alimentaie

f. virali: EBV - RF; HPV - cav. bucal, laringe?

cavitate nazal/sinusuri: industria lemnului

sindr. Plummer-Vinson: F, limb, reg. RCA
10/4/2013 NG2005 5

Tumorile ORL: Generaliti (4)

3. Istorie natural

histologie:
carcinom - 80%

limfom - 15-20%
adenoCa - rar: glande salivare

sarcom - rar: copii

10/4/2013 NG2005 6

Tumorile ORL: Generaliti (5)

3. Istorie natural

evoluie local & locoregional de lung durat

limfofilie accentuat:

topografie caracteristic pctului de plecare

uni- vs bilateral

tratament multidisciplinar: chir & RT & CT

eecuri predominent loco-regionale duble T primare: 20-30% = field cancerization
10/4/2013 NG2005 7

Tumorile ORL: Generaliti (6)

4. Prezentare clinic: ulceraie leziune infiltrativ exofitic Semne/simptome: in funcie de localizare

T primar
10/4/2013 NG2005

adenopatia

Tumorile ORL: Generaliti (7)

4. Prezentare clinic:

adenopatie:
orice adenopatie care persist mai mult de o sptmn la un adult: malign! peste 40 ani: practic ntotdeauna malign! topografie caracteristic

10/4/2013

NG2005

Tumorile ORL: Generaliti (8)

4. Structurile anatomice ale capului i gtului

10/4/2013

NG2005

10

Tumorile ORL: Generaliti (9)

10/4/2013

NG2005

11

Tumorile ORL: Generaliti (10)

Punct de plecare probabil Nivel I submenton submandib Nivel II Nivel III Nivel IV

buza inf, planseu bucal, limba mobil buza sup&inf, limba mob, fa cavit bucal, oro/hipofaringe laringe, hipofaringe, tiroid laringe, hipofaringe, tiroid, esofag cervical, trahee

Nivel V RF, tiroida, scalp post Supraclavic Localizri infraclavic (esofag, plmn, sn, tract 10/4/2013 12 digestiv, etc) NG2005

II. Localizri: cavitate bucal (1)

1. Cavitatea bucal:

predominent B: fumat, alcool, UV

durere local, otalgie unilateral histologie: carcinom TP: ulceraie, infiltraie: persistent, recidivant! extindere: contiguitate, infiltrativ

inspecie & palpare: ulceraie indurat

adenopatie submentonier, submandibular 10/4/2013 tratament: TP (chirurgie + RT) + ganglioni! NG2005
13

Cavitate bucal (2):

Subdiviziuni:

buze
limba mobil (2/3 ant)

mucoasa bucal
rebordul alveolar inf & sup trigonul retromolar,

planeul bucal
palatul dur
10/4/2013 NG2005 14

II. Localizri: buz (3)

10/4/2013

NG2005

15

II. Localizri: buz (4)

10/4/2013

NG2005

16

Limb

10/4/2013

NG2005

17

 mucoas jugal planseu bucal rebord alveolar

10/4/2013

NG2005

18

2. Orofaringe:
subdiviziuni: pilierul amigdalian ant, palatul moale / uvula, fosa amigdalian & amigdala palatin, baza limbii, pereii faringieni lateral & posterior

B:F = 4:1, mediana 55-65 ani

extindere: contiguitate, infiltrativ

tratament: RT CT C
10/4/2013 NG2005 19

2. Orofaringe: amigdal & trigon; baza limbii

10/4/2013

NG2005

20

2. Orofaringe:

disfagie, durere local, odinofagie, otalgie

persoane n vrst: posibil asimptomatice

probleme protetice
inspecie & palpare & ex. oglind:

10/4/2013

NG2005

21

Tumorile ORL: Generaliti (7b)

10/4/2013

NG2005

22

Tumorile ORL: Generaliti (7d)

CC amigdalian: la diagnostic i dup RT

10/4/2013

NG2005

23

Limfom amigdalian

10/4/2013

NG2005

24

Limfom amigdalian

10/4/2013

NG2005

25

Orofaringe: baza limbii, amigdala

10/4/2013

NG2005

26

3. Rinofaringe

Epidemiologie:
vrst: distribuie bimodal adolescen + aduli tineri vs 50-70 ani fr asociere cu tutun, alcool

EBV
10/4/2013 NG2005 27

3. Rinofaringe
Prezentare clinic epistaxis, hipoacuzie, obstrucie nazal

durere atipic: trigemen invazia bazei craniului

semne neurologice: durere facial, diplopie, disfonie

interesare nervi cranieni: V, VI, II-VI, IX, XI

respectarea VII, VIII adenopatii 60%, bilaterale, spinale

metastaze, recidive tardive

Tratament: RT CT
10/4/2013 NG2005 28

3. Rinofaringe

10/4/2013

NG2005

29

Rinofaringe: CT

10/4/2013

NG2005

30

Rinofaringe: clinic, rinoscopie post

10/4/2013

NG2005

31

3. Rinofaringe

10/4/2013

NG2005

32

3. Rinofaringe
Extensie endocranian Adenopatii multiple, bilaterale

10/4/2013

NG2005

33

Rinofaringe: N

10/4/2013

NG2005

34

4. Fose nazale & caviti paranazale

inciden redus, median 50-60 ani

evoluie mascat: proces inflamator cronic:

epistaxis, obstrucie nazal, secreie mucopurulent, sanguin tumefiere obraz, durere,

diplopie
tratament: C RT CT
10/4/2013 NG2005 35

Sinus maxilar & etmoid: CT

10/4/2013

NG2005

36

5. Laringe & hipofaringe

Subdiviziuni: glotic vs supra- vs sub- glotic

Simptomatologie:
disfonie persistent

otalgie, durere local: tardiv

dispnee, stridor: idem adenopatie: frecvent uni/bilat, rar formele glotice cazuri avansate: dispnee, stridor, dispariia 10/4/2013 NG2005 cracmentului laringian
37

5. Laringe & hipofaringe Hipofaringe: frecvent asimptomatic

disfagie, odinofagie, otalgie

disfonie

mas ganglionar unilateral

inspecie & palpare & ex. oglind: leziunea, mobilitatea structurilor laringiene
Tratament: C vs RT CT = conservarea 10/4/2013 NG2005 fonaiei!!!
38

5. Laringe & hipofaringe

Subdiviziuni
anatomice: L supraglotic: vestibul L glotic: CV L subglotic H sinus oiriform
10/4/2013 NG2005

H reg RCA

39

5. Laringe & hipofaringe: adenopatia

10/4/2013

NG2005

40

5. Laringe & hipofaringe

4. Laringe: CV

10/4/2013

NG2005

41

5. Laringe & hipofaringe

Laringe supraglotic Hipofaringe: sinus piriform

10/4/2013

NG2005

42

6. Tumori glande salivare

interesare egal ambele sexe

mediana 40-50 ani

80% n parotid: 2/3 benigne

10% gl. submandibulare: 50% benigne

10% gl. salivare minore: 2/3 maligne!

10/4/2013

NG2005

43

6. Tumori glande salivare

Prezentare

tumefiere parotidian: cretere rapid, durere local, paralizie facial, trismus, adenopatie gl. submandibulare: tumefiere ferm, nedureroas
gl. salivare minore: leziuni nodulare submucoase, de obicei palatul dur, fr ulceraie
10/4/2013 NG2005 44

6. Tumori glande salivare

Extindere

contiguitate local, piele, mandibul, compresiune extrinsec faringian perineural: ca adenoid chistic
limfatic: 25-60%

hematogen: 30-50% (CC mucoepidermoid vs ca adenoid chistic)

10/4/2013 NG2005 45

6. Tumori glande salivare

CT: lobul profund

10/4/2013

NG2005

46

Tumorile ORL: III. Stadializare & Tratament & Urmrire

Stadializare:
TNM factori de prognostic: punctul de plecare stadiul T & N comorbiditi
10/4/2013 NG2005 47

Tumorile ORL: III. Stadializare & Tratament & Urmrire

Tratament:

multidisciplinar
C vs RT, stadii iniiale: L, cav. bucal

predominent chirurgical: gl. salivare, sinusuri, HF, mutilant vs conservator predominent RT: RF, OF
stadii avansate: RT&CT (DDP+5FU) 10/4/2013 concomitent C NG2005
48

Tumorile ORL: III. Rezultate (1)

Localizare Cav bucal limba mob planseu mucoasa buc trigon RM gingia inf buza inf OroF Amigdal Baza limbii perete F palat moale
10/4/2013

S% 5 ani 45 50 45 60 65 85 45 30 20 50
NG2005

I-II

III-IV

80-60 80-70 75-65 75-70 75-60 90-85 90-60 60-40 50-30 85-60

30-15 60-30 30-15 60-30 50-30 70-60 40-15 20-10 20-10 30-15
49

Tumorile ORL: III. Rezultate (2)

Localizare Rinofaringe Laringe glotic supraglotic Hipofaringe Sinus piriform reg. RCA Sinus maxilar
10/4/2013

S% 5 ani 45 85 55

I-II 60-40 95-85 65-65

III-IV 30-15 60-35 55-40

25 20 25
NG2005

30-20

15-5

35

15
50

Tumorile ORL: III. Urmrire

recidiva local, loco-regional

metastaze: pulmonare, osoase

a 2 TM: epiteliul respirator, urinar comorbiditi: cardio-vasculare recuperare nutriional, fonatorie prevenie !!!!!
10/4/2013 NG2005 51