CANCERELE

ORL

1. Fose nazale & sinusuri paranazale

2. Faringe: nazo-, oro-, hipofaringe (HF)
3. Cavitatea bucala + buze/vestibul bucal
4. Laringe (LA)
5. Glande salivare (GS Majore, minore)
6. Tiroida
7. Alte: ureche, vestibul nazal, tegumentul
fetei…..
all the images in this presentation are Frederick III 
…… only for teaching purposes Predecessor: Wilhelm I
Successor: Wilhelm II
 CARACTERISTICI COMUNE Cc SFERA ORL

- Etiologie: tabac, alcool concentrat, HPV/EBV  al-2lea cc sfera ORL (20%)

- Histologie: carcinom epidermoid > 90 % ; ADK, limfom, melanom, sarcom

- Istorie naturala/extindere:  LOCO-REGIONALA (T & N)  voce, deglut

- meta la distanta rare
(exceptii: RF, adenoid-chistic*)

- LIMFOFILIE precoce, frecvent bilaterala  ggl cervicali de tt. intotdeauna

- tu oculta (primitiv necunoscut= Tx)

 tripla biopsie (RF, SP, BL) +/- Amigdalectomie ipsilaterala

 EXAMINARI (clinic/paraclinic)  STADIU CMD  TRATAMENT

- BILANT: IP, CP, evaluare nutritionala si dentara

- tripla endoscopie (= ORL complet + bronho + esofago-scopie)
 BIOPSIE (BIOPSII)
- imagistica (CT, RMN, PETCT)
- status HPV (OF)
- f. cardiaca, renala, hepatica (comorbiditati, eligibil CHT)

 STADIU TRATAMENT: 1. prezervare functionala

2. multidisciplinar
3. T & N nedisociate
Factori de prognostic (in general pt cc ORL)

I. Tumorali (cuprinsi in std TNM)

1. Localizarea
2. Dimensiune/extensie
3. Prezența/absența meta ggl – nr, dim
4. Prezența metastazelor la distanță

II. Histologici
1. Grad de diferențiere histologic – pt rinofaringe
2. Invazie perineurală, vasculară (L1V1)
3. Efracție capsulară ganglionara (EEC)

III. Terapeutici
1. Margine de rezecție pozitivă
2. Interval peste 6 saptamani între chirurgie si RTE

IV. Legati de gazda:

1. IP, CP
2. HPV, EBV
3. Co-morbiditati ( Insuf renala = c-ind pentru Cisplatin)
 RADIOTERAPIE : 1. EXTERNA
2. BRAHITERAPIE
3. IRATERAPIE (131I in cc diferentiat de tiroida)

TRATAMENT cc
sferei ORL

- TT SISTEMIC CHIRURGIE:
1. CHIMIOTERAPIE : a) concomitenta cu RT (nu > 70 ani) - conservativa;
b) Neoadjuvanta (faring-laringe) - non-conservativa
c) Adjuvanta (RF)
2. IMUNOTERAPIE:
- CETUXIMAB (antiEGFR) : concom if CT c-ind/ M1
- PD1/PDL1 inhib: pt recidive inop sau M1
Toxicitate

 Radioterapie
 toxicitate cutanată (radioepitelită)
 conjunctivită
 Mucosită
 alterări ale gustului
 Xerostomie
 Epilare
 Edem - !!! Edem laringian
 Sdr Lhermitte- rar: senzație de șoc electric la nivelul membrelor superioare
la flexia gâtului
 Reacții adverse tardive: xerostomie, epilare
 Toxicitate

Chimioterapie
 concomitent cu RTE: crește frecventa și intensitatea r adv ale RTE

 Cisplatin: - toxicitate renală -!!!!!hidratare parenterala + p.o

- neuropatie periferică
- emeză
- ototoxicitate: surditate în special pentru frecvențe înalte
- mielosupresie

 Docetaxel: - neutropenie
- reacții alergice - !!!! Premedicație: corticoterapie
- neuropatie periferică
- alopecie

 5-Fu: - mielosupresie (mai puțin exprimată la adm în perf continuă

- epifora
- fotosensibilitate
- hiperpigmentare traiecte venoase perfusate
- toxicitate cardiaca!!!
Supraviețuire

Rinofaringe: 76% la 1an

50% la 5 ani

Restul localizarilor: 70% la 1 an

40% la 5 ani

std I: 80-100 %  std IV: 15-25 %

Grégoire V, et al. Delineation of the neck node levels for head and neck tumors: a 2013
update. DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG, TROG consensus
guidelines. Radiother Oncol. 2014 Jan;110(1):172-81. doi:
10.1016/j.radonc.2013.10.010.
 REPERE conturaj ggl
(vase…. ACI, VJI)

OASE: Mastoida, Atlas (C1), MANDIBULA, HIOID, Clavicula/stern

Cartilaje: Cricoid, (tiroid)

Muschi: prevertebrali,ridicator val palatin (RetroF)

milo-H, SCM, Trapez, platysma, sterno-H

Glande: submandibulara & tiroida

Drenaj limfatic nivel/functie de localizare

Ia: teg. fata/obraz, 1/3mijloc buza inf, vf limbii, rebord alv inf-ant, planseu ant
Ib: cantus med, 1/3 inf fosa nazala, palat, rebord alv*, buze*, limba/planseu*, GsM
IIa (ant de VJI): Gl salivare maj, fosa nazala *, faringe, laringe, CAE/ureche medie
IIb (post de VJI): RF, OF
III: BL, amigdala, La, HF, tiroida
IV: LA, HF, esofag cervical
Va (cervical post): scalp occipital, teg gat postlat, RF, OF (BL, amigdala), HF (SP)
Vb (SCV)- laringe subglotic, esofag cervical, RF, tiroida
VI: tiroida
Retrofaringieni: RF, OF, HF
Chao KSC et al. Int J Radiat Oncol Biol Phys 2002;53:1174
Adenopatie retrofaringiană
Extindere ggl extracaps
(EEC)

96 % ≤ 5 mm, 100 % ≤10 mm

1 cm: 17-40 % EEC (+)
-3 cm: 38- 63 %
>3 cm: 67-95 % EEC(+)
Apisarnthanarax S et al. Int J Radiat Oncol Biol
Phys 2006;64:678

- Ajustat pt oase, aer, partial pt muschi

 FOSE NAZALE & SINUSURI PARANAZALE

I. FOSE NAZALE (dr/stg): ▲Baza craniu;▼palat dur

Post= CHOANE comunica direct cu RF
Lat: oase & cartilaj = aripa nazala
Med- sept nazal/ deviere frecventa
-3 cornete (S,M,I), 3 meaturi (Sup- cel etm post, Sinus sfenoid;
Mijl -cel etm ant, Sinus Frontal & Maxilar;
Inf -canal NL);
- post: raport cu fosa pterigopalatina
Extindere facila: sup prin lama cribrif.  fosa cerebrala ant
post prin choane—RF
lat- sinsuri, fosa pterigo-palatina
- GGL:  submandibulari (Ib)- 1/3 ant/inf,
jug carot sup ant (IIa)- 2/3 post-sup
 FOSE NAZALE & SINUSURI PARANAZALE

II. SINUSURI PARANAZALE:  ggl RF/ IIa, limfofilie 5-20 % < fose nazale
1. ETMOID: - celule etm. Ant & Post, fara bariere anat. intre ele
- lat:  prin lamina papiracee ORBITA, nv optic!
- sup:  prin lama cribriforma fosa cerebrala ant;

2. SFENOID: -Dr/stg; sept asimetric, inconstant

- comunicare cu fosa nazala/ SE prin reces sfeno-etmoidal
- proximitate chiasma optica & hipofiza (sup)
sinus cavernos /III,IV, VI/ & fosa cerebrala medie
trunchi cerebral (post)
 FOSE NAZALE & SINUSURI PARANAZALE

II. SINUSURI PARANAZALE:

3. MAXILAR- dr/stg: = piramida cu vf post, sub orbita (bariera slaba)
-post = fosa infratemporala si fosa pterigo-maxilara gauri baza
cran
-inf:  prin radacinile molari rebord alveolar/cav bucala

4. FRONTAL: - dr/stg/ sept deviat+/-

- perete post osos= bariera spre fosa cerebrala ant

Linia Ohgren (cantus medial  gonion): “Infrastruct” progn (+) vs.

suprastruct
RADIOTERAPIA EXTERNA cu
INTENSITATE MODULATA (IMRT)
Caz
Fosa nazala cu extindere pansinusala
 NASOPHARYN
X

Harnsberger's Diagnostic Imaging Head and Neck 3rd edition,

2017
 NAZOFARINGE (RF)

◄Choane ▲sinus sfenoidal ►Fascia Faringo-bazilara*/ Clivus+ Atlas+ Axis; ▼palat

moale; Lateral = fascia faringiana* (imediat medial de ACI) SpPF;

Bolta RF FNz, Sinus Sf/etm post/ gauri baza craniu  Fosa cerebrala mijlocie
Pereti lat (FR)  SPF/ m pterigoidieni/ OF (pereti lat);
Perete post perete post OF/ fascia prevertebrala erodare clivus

LIMFOFILIE ++ (70-90%): RetroF, IIa-b, V; parotidieni (via lf trompa Eustachio)

Natural History
Histology
Squamos cell carcinoma - Non-keratinizing and keratinizing
Undifferentiated carcinoma
Point of origin
Most common is from the Rosenmuller fossa

Please check out radiopaedia.org

 Extensie superioară

Extensie lateral (CT)

SIGNS &
SYMPTOMS
NATURAL HISTORY Often, nerves and base of skull involvement
!

Harnsberger's Diagnostic Imaging Head and Neck 3rd edition,

2017
20180116_130213 RF.mp4

20180123_125146 RF.mp4
STAGING

T1 T2

T3

T4

UICC-AJCC TNM 8th edition, 2018

TNM Atlas 6th edition
DIAGNOSIS & WORK-UP

NCCN Head and Neck Cancers, version 3.2019 September 16,

2019
TREATMENT

Induction chemo:
TPF=taxan+platină+fluorouracil
(Docetaxel+Cisplatin+5-
Fluorouracil) Concurrent chemo:
Cisplatin

NCCN Head and Neck Cancers, version 3.2019 September 16,

2019
 TREATMENT

CONCURRENT

RADIOCHEM
O THERAPY
High-risk CTV
(including
GTV) ≈ 70 Gy
Intermediate-risk
CTV ≈ 60 Gy
Low-risk CTV ≈
50
Gy

CHEMOTHERAPY

SURGERY

Taheri-Kadkhoda Z, et al. Intensity-modulated radiotherapy of nasopharyngeal carcinoma: a comparative treatment planning study of photons and
protons. Radiation Oncology. 3(4), 2008.
 A. GTV-gross tumor
volume
B.
(what
CTV-clinical
can be seen)
target
(microscopic extension)
volume
TARGET
ORGANS AT C. PTV-planning target volume
VOLUMES
RISK (daily positioning errors or
organ motion)
PROGNOSTIC FACTORS & RESULTS

The 5-year survival rate:

stage I: 72%.
stage II: 64%
stage III: 62%
stage IV: 38%
https://www.cancer.net

UICC-AJCC TNM 8th edition, 2018

 OroPHARYN
X

Harnsberger's Diagnostic Imaging Head and Neck 3rd edition,

2017
 OROFARINGE (OF)

Amigdala palatina + pilier ant/post;

Baza limbii;
Palat moale;
Perete post al OF

- valecule, sant gloso-amigdalian, “amigdala linguala”

- (+ TRM ca si cai de extindere, desi apartine cavitatii bucale);

Limfofilie crescuta, frecvent bilaterala (BL > amigdala)

HPV  std separata in Ed 8 pt HPV(+)

ANATOMY (oropharynx limits + lymphnodes)

EPIDEMIOLOGY – 5th, 7th, ♂

RISK FACTORS – viral (HPV), environmental (tobacco, alcohol)

NATURAL HISTORY

Harnsberger's Diagnostic Imaging Head and Neck 3rd edition,

2017
SIGNS & SYMPTOMS

Infiltrarea limbii → disartrie

Infiltrarea mușchilor pterigoidieni → trismus

Tumefacție retroangulomandibulară  70% cu ADP la dg

Dis- și odinofagie  scădere masa

corporală

Otalgie reflexă
Sângerări
STAGING T1
T1 Tumour 2 cm or less in greatest dimension
T2 Tumour more than 2 cm but not more than 4 cm in
greatest dimension
T3 Tumour more than 4 cm in greatest dimension or extension
to lingual surface of epiglottis
T4a Tumour invades any of the following: larynx,*
deep/extrinsic muscle of tongue (genioglossus, hyoglossus,
palatoglossus, and styloglossus), medial pterygoid, hard
palate, or mandible T2
* Mucosal extension to lingual surface of epiglottis from primary tumours of
the base of the tongue and vallecula does not constitute invasion of the
larynx.
T4b Tumour invades any of the following: lateral pterygoid
muscle, pterygoid plates, lateral nasopharynx, skull base; or
encases carotid
NX Regional artery
lymph nodes cannot be
assessed N0 No regional lymph node
metastasis T3
N1 Unilateral metastasis, in lymph node(s), all 6 cm or less in
greatest dimension
N2 Contralateral or bilateral metastasis in lymph node(s), all 6 cm
or less in greatest dimension
N3 Metastasis in lymph node(s) greater than 6 cm in dimension
M0 No distant
metastasis M1 Distant T4
metastasis

TNM Atlas 6th edition

DIAGNOSIS & WORK-UP

Treatment differs depending on the p16 status - as a marker for HPV-related head
and
TREATMENT

CONCURRENT
RADIOCHEMOTHERAPY
High-risk CTV (including GTV) ≈ 70
Gy Intermediate-risk
Low-risk CTV ≈ 50 Gy CTV ≈ 60 Gy
*in study: lower doses for p16+ tumours

SURGERY

CHEMOTHERAPY
Induction chemo:
TPF=taxane+platinum+fluorouracil (Docetaxel+Cisplatin+5-
Fluorouracil)
Concurrent chemo:
Cisplatin
Reiradiere (al 2-lea cancer)- Baza limba:
BRAHITERAPIE Interstitiala
TREATMENT

NCCN Head and Neck Cancers, version 3.2019 September 16,

2019
 PROGNOSTIC FACTORS & RESULTS

Tumor-related
>3 cm, origin, N+, stage
Histological
Depth of invasion, Pn+, V+,
grade, extracapsular extension
Therapeutic
R+, >6 weeks between
surgery and
radiochemotherapy
Performance status
Propedeutică oncologică, 2008

UICC-AJCC TNM 8th edition, 2018

5-year survival rate:

-84% if the cancer is diagnosed at an early stage;
-65% if the cancer has spread to surrounding tissues or organs and/or the regional lymph
nodes;
-39% if the cancer has spread to a distant part of the body.
https://www.cancer.net
 Hy phoPHARY
NX

Harnsberger's Diagnostic Imaging Head and Neck 3rd edition,

2017
 HIPOFARINGE (HF)

Sinus piriform, reg retro-cricoidiana, perete post al HF

M. constrictor inf ai faringelui  cale de extindere spre Baza Craniu

Limfofilie ++

Invazie laringe/ cartilaj  “tumori faringo-laringiene”

Disfagie/ odinofagie/ otalgia reflexa

 LA RYNX

Harnsberger's Diagnostic Imaging Head and Neck 3rd edition,

2017
Meds

ape
c
ANATOMY

Thieme Atlas of Head, Neck and Neuroanatomy, 2nd edition,

2016
 NATURAL HISTORY

Medsca
pe
Helliwell T, et al. Data Set for the Reporting of Carcinomas of the Hypopharynx, Larynx, and Trachea: Explanations and
Recommendations of the Guidelines From the International Collaboration on Cancer Reporting. Arch Pathol Lab Med.
2019 Apr;143(4):432-438.
20180125_102025 La -HF normal.mp4

20180130_135158 SP.mp4

20180131_125724 HF.mp4
STAGING
T stage T1
depends
whether the
tumor is
supraglottic,
https://headandneckcancerguide.org
glottic or (see
infraglottic
UICC-AJCC
TNM
8th edition)
T2 T
3

NO Vocal
fixatio cord
n fixatio
n
T4

destruction
M0 No distant
metastasis M1 Distant
metastasis TNM Atlas 6th edition

UICC-AJCC TNM 8th edition,

SIGNS & SYMPTOMS

Supraglotic → disfagie, tulburări de deglutiție, disfonie

dacă invadează spațiul glotic, adenopatii

Glotic → disfonie (dg precoce)

*tumorile glotice T1 nu dau adenopatii (corzile vocale NU
au drenaj limfatic!)

Insuficiență respiratorie acută (...) !

DIAGNOSIS & WORK-UP

this is a bird’s-eye view of glottic laryngeal cancer treatment, as an

example NCCN Head and Neck Cancers, version 3.2019 September 16,
 TREATMENT

-Organ-preservation strategy as primary goal! “Life-preserving” strategy

-otherwise
-DO NOT irradiate if cartilage destruction→chondritis→acute respiratory failure!!!
CONCURRENT
RADIO(CHEMO
O THERAPY
High-risk CTV
(including GTV)
≈ 70 Gy
Intermediate-
risk CTV ≈ 60
Gy Low-risk
CTV ≈ 50 Gy
SURGERY
(including eg. laser
CO2 cordectomy for
early stages)
CHEMOTHERAP
Cuny F. Exclusive radiotherapy for stage T1-T2N0M0 lanryngeal cancer: retrospective study of 59 patients at CFB and
CHU de Caen. Eur Ann Otorhinolaryngol Head Neck Dis. 2013 Nov;130(5):251-6. Y
PROGNOSTIC FACTORS & RESULTS

5-year survival rate:

->90% if the cancer is diagnosed at
an early stage;
-78% if the cancer has spread
outside
the larynx;
-46% if the cancer has spread to
surrounding tissues or organs
and/or the regional lymph nodes;
-34% if the cancer has spread to
a distant part of the body.
https://www.cancer.net

UICC-AJCC TNM 8th edition, 2018

 CAVITATEA BUCALA (CB)

Buza sup/inf, sant gingivo-bucal, gingia sup-inf (+rebord alveolar), palat

dur, mucoasa bucala (inclusive TRM), planseul bucal , 2/3 ant ale limbii
Limba mobila - 4 m. extrinseci: genio-/ hio-/stiloglos (XII) + palatoglos (X)
- senzitiv - nv lingual (din V3)
- gustativ - VII (coarda timpanului)
Planseu – fren lingual, duct Wharton (SM), gl sublinguale
 periost, mandibula, IPN (idem pt TRM)
Buze- mucoasa/vermilion/tegument; m orbicular al gurii.
- Drenaj lf ggl nivel Ia (submentonieri); T1 (<2 cm) +LN ≤ 5%  no LN tt
 GLANDE SALIVARE

Majore (P, SM, SL) & minore (cai aerodig sup + aberante: ureche medie, duct tireoglos,
retromolar etc).
Rare (3-4 % ccORL); doar 25 % din tu GSM sunt maligne; primar < LNH/ meta

Std ≈ idem cav bucala (2/ 4 cm…) ; limfofilie medie(20-25 % N+/pN+ la dg)

PAROTIDA: fascie, lob superf > profund  spatial parafaringian

duct salivar M2 sup
nv facial, auriculotemporal  PNI  baza craniu; paralizie perif
ggl intraparodieni (4-10), sub-parotidieni intra-fasciali

SUBMANDIB, SUBLINGUALE: parti moi (m. planseu, tegument) & os

(mandibula)/PNI
 TIROIDA

2 lobi, +/- lob pyramidal, +/-istm, +/- tesut accessor/duct T-G;

Cel foliculare = “capcane de iod” – secreta colloid ( = tireoglobulina, contine T3,4)
Cel parafoliculare neuroendocrine (cellule C) cc medular ( calcitonina)
Cel stromale sarcoame
Limfocite  LNH
 ORL2 –….

Stagiul urmator = cazuri clinice