Roberto B.

Acua, MD
FPCS, FPALES, FPSGS, FPBCS

General & Cancer Surgery

Laparoscopic Surgery

FEU-NRMF Medical Center

Bernardino General Hospital I & II
St. Lukes Medical Center
TOPICS
MUCOSAL CANCER
INCIDENCE &
EPIDEMIOLOGY
Sex
Usually men (3:1)

Location
Oral & pharynx in whites

Laryngeal in blacks
MUCOSAL CANCER
ETIOLOGY
Sunlight exposure EBV
Tobacco use Genetic
Chew tobacco >> Buccal Retinoblastoma q14 chr 13
Reverse smoking >> Hard palate Medullary thyroid ca chr 10
Pipe smoking >>Lip Neurofibromatosis chr 22
Cigarette smoking >>Tongue, pharynx,
larynx, esophagus, lungs Poor oral hygiene
Floor of the mouth, tongue, gums
Alcohol
Radiation therapy
Nutritional deficiency
Occupational factors
Mucosal Cancer
PATHOLOGY
Exophytic or Ulcerative

Histology:
SCC 90%
Adenocarcinoma
Verrucous carcinoma

Mode of Spread
Lymphatic mostly
Mucosal Cancers
CLINICAL FEATURES
An obvious lesion
Bleeding
Malodorous breath
Odynophagia
Otalgia
Trismus
Nasal stuffiness, unilateral
nasal obstruction,
headache and epistaxis
Nasal speech
Hot potato voice
Poorly fitting dentures
Loosening of teeth
Dysphagia
Hoarseness
Cranial nerve palsies
Cervical adenopathy
80% TB if without primary
tumor/malignancy
85% metastatic if with
primary H & N malignancy
Mucosal Cancer
Diagnosis
History
Risk Factors
Signs and symptoms
Physical examination
Bimanual
Imaging
Xray or CT scan

MRI

PET scan
Mucosal Cancer
DIAGNOSIS
Biopsy for lesions evident
on PE or imaging
Superficial
Punch biopsy
Deeper lesions
FNAC
Core needle biopsy
Incision biopsy
Excision biopsy
Role of Endoscopy
Biopsy of Nasal, Pharyngeal, Laryngeal, Esophageal
lesions
For non-evident lesions
(+) SCC on LN biopsy
Occult primary

Random biopsy of NP, pyriform sinus, base of tongue, tonsillar

pillars
Still negative
Neck dissection if SCC of LN
If adenoca, lymphoma >> stop
Thoracic or abdominal source
Mucosal Cancer Treatment
Surgery

Radiotherapy

Chemotherapy
Mucosal Cancer Treatment
Surgery
Complete removal of mass
Neck Dissection
Radical Neck Dissection
Modified Radical Neck
Dissection
Selective Neck Dissection
Radical Neck Dissection
Lymphatic structures
Cervical nodes level 1-6

Non-lymphatic structures
SCM
IJV
CN 11
Modified RND
Selective ND
Mucosal Cancer
TREATMENT
Radiotherapy
NPCa
Other indications
Inadequate margins
Poor risk for surgery
Palliation for pain control
Mucosal Cancer
Chemotherapy
Adjunctive or palliative treatment only

Methotrexate, 5FU, bleomycin, cisplatin, hydroxyurea

Major Salivary Glands
Parotid
Submandibular and Sublingual Glands
Minor Salivary Glands
SALIVARY GLAND TUMORS
EPIDEMIOLOGY
Parotid glands
Most common site of salivary gland tumors
70-80% are benign
Submandibular & sublingual glands
50% are benign
Minor salivary glands
Least common of the salivary gland tumors
60% are malignant
Benign Tumors
Pleomorphic Adenoma
(benign mixed tumor)
80% of all benign tumors
of parotid gland
Unilateral
No nerve involvement
Usually middle aged
women
2-5% sarcomatous
degeneration
Benign Tumors
Warthins Tumor
Benign papillary
cystadenoma
lymphomatosum
2nd most common
Older males
10% bilateral
Malignant Tumors
Mucoepidermoid cancer Causes
Tumor grade impt. Chewing tobacco
Smoking
Symptoms
Painless lump with Diagnosis
facial nerve paralysis FNAC
Incision biopsy
Parotidectomy
Thyroglossal Duct Cyst
Branchial Cleft Cyst
Lymph Nodes
Lymphangiomas
Lymph Nodes
80% tuberculous

If with primary head and

neck cancer, 85%
metastatic

Diagnosis
FNAC
Incision biopsy
Excision biopsy
Thyroglossal Duct Cyst

SISTRUNK OPERATION
Branchial Cleft Cyst
Type I
E: U/3 of SCM
I: Ext. auditory canal
Type II
E: M/3 of SCM
I: Tonsillar fossa
Type III
E: L/3 of SCM
I: Larynx
DIFFUSE VS. NODULAR
 Thyroid Hormone Production
X
I
- - 2 MIT T3, PLASMA T3, T4
I I + TG
DIT T4

TRAPPING OXIDATION IODINATION COUPLING

X X
Cyanogenic goitrogens Turnips
Cabbage
Cassava Garlic
Corn Onion

Bamboo shoots
Sweet potatoes
E. Coli & Aerobacter
PTU, Carbimazole, Methimazole
exotoxin

PTU
Thyroid Function Tests
TSH
FT3, FT4
1. FT3, FT4, TSH frank hyperthyroid
2. FT3, FT4, TSH mild hyperthyroid
3. FT3, FT4, TSH T3 toxicosis
4. FT3, FT4, TSH frank hypothyroid
5. FT3, FT4, TSH mild hypothyroid
6. FT3, FT4, TSH 2o hyperthyroid
7. FT3, FT4, TSH 2o hypothyroid
Thyroid Function Tests
TSH
FT3, FT4
Thyroid scan with 123I
Cold nodule 21% Ca
Warm nodule 12% Ca
Hot nodule 7% Ca

Single or multiple nodules

Graves disease 5-7% Ca

Other Tests for Thyroid
Thyroid ultrasound
Volume analysis
Diffuse vs. nodular

Cystic 4% malignancy rate

Mixed 9%

Solid 16%

Thyroglobulin
24hr 131I uptake
FNAC
CT scan
GOITER
EPIDEMIOLOGY PHYSICAL EXAMINATION
Females > Males Look at gland
Iodine deficiency Diffuse vs. Nodular
Follicular cancer Take pulse
Iodine excess Euthyroid <90/min
Papillary cancer Hyperthyroid >90/min
Treatment may be based on Palpate thyroid
physical examination only Confirms #1
Palpate LN
(+) means papillary cancer
SURGERY FOR GOITERS
PROGNOSTIC FACTORS in CA SURGICAL OPTIONS
G Tumor grade Less-than-total
A Age > 45yo Thyroidectomy
M Metastasis Lobectomy + isthmusectomy
Ipsilateral total lobectomy +
E Extrathyroidal spread
contralateral subtotal
S Size >4cm lobectomy (subtotal)
Near total thyroidectomy
Total Thyroidectomy
Thyroid Cancer in the Philippines
1998 2010
7th leading cancer 11th leading cancer
4th in women 9th in women
7th in men 17th in men
Male-to-female ratio 1:3
Most common cancer in 16th leading cause of cancer
women 15-24 y/o death
SEER data 2006-2010
Median age at diagnosis Median age at death for
is 50 y/o thyroid cancer is 73 y/o
< 20 y/o 2%
20 -34 y/o 15%
35 - 44 y/o 20%
45 54 y/o 24%
Relative 5-year survival
55 -64 y/o 19% rate is 97.7%
65 -74 y/o 12%
75 -84 y/0 6%
> 85 y/o 2%
World Data (SEER 2006-2010)

Race/Ethnicity Male (per 100,000) Female (per 100,000)

All Races 6.1 18.2
White 6.6 19.4
Black 3.2 10.5
Asian/Pacific Islander 5.3 17.9
American Indian/Alaska
3.3 11.0
Native a
Hispanic b 4.4 16.4
Thyroid Cancer
Well-differentiated
Papillary 80-90%
Follicular variant

Occult papillary cancer (OPC)

Follicular

Intermediate
Hurthle cell
Medullary thyroid cancer (MTC)

Undifferentiated
Anaplastic
Types of Thyroid Cancer

Normal thyroid Follicular Cancer (FTC)

Papillary Cancer (PTC) Medullary Cancer (MTC)

AJCC Staging of Thyroid Cancer
T0 No evidence of primary tumor
T1 Tumor 2 cm
T2 Tumor > 2cm to 4cm
T3 Tumor > 4 cm
T4 Any size but extends beyond the thyroid

N0 No nodal metastasis
N1 With nodal metastasis

M0 No distant metastasis
M1 With distant metastasis
Staging of Papillary and Follicular Cancer, < 45 y/o
Stage 1. No mets Stage 2. With mets
Staging of Papillary and Follicular Cancer, 45 y/o
Stage 1. T1, N0, M0 Stage 2. T2, N0, M0
Staging of Papillary and Follicular Cancer, 45 y/o
Stage 3. T3, N0, M0 or T1-3, N1a, M0
Staging of Papillary and Follicular Cancer, 45 y/o
Stage 4. T4, any N, M0or any T, any N, M1
Staging of Medullary Thyroid Cancer
Stage I. T1, N0, M0 Stage III. T3, N1a, M0

Stage II. T2-3, N0, M0 Stage IV.

T4a, any N, M0
T1-3, N1b, M0
T4b, any N, M0
Any T, any N, M1
Complications of Thyroidectomy
Bleeding

Organ injury
Parathyroid

Nerve injury
Superior Laryngeal Nerve
High pitch nerve
Inferior Laryngeal Nerve
Recurrent Laryngeal Nerve
SUBTOTAL THYROIDECTOMY
Functions of the Parathyroids
Parathyroid hormone
(PTH)
serum calcium
Increased bone resorption
osteoclast activity
Ca++ absorption in GIT by
activating vitamin D
renal calcium reabsorption
phosphate
PCT, DCT reabsorption
osteoblast activity,
hence, bone formation
Hypoparathyroidism
Most common cause is
surgical destruction
Signs and symptoms
Peri-oral tingling
sensation
Tingling in hands and
feet
Opisthotonus and
seizure
CHVOSTEK SIGN
Hypocalcemia
Treatment
Calcium
Vitamin D
PTH