Journalof Audiovisual Media in Medicine 1978,1,156-160
Patterns of spread in carcinoma of the head and neck- a pictorial essay
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
R . L. CARTER and K. G.MOREMAN The cardinal feature of malignant tumours is their capacity to invade locally and spread to distant sites, a process known as metastasis. It is important to recognize that the extent of invasion and metastasis varies with different tumours arising at different sites. Cerebral gliomas. for example, are invasive within the central nervous system but metastatic spread outside the craniospinal cavity is exceptional. In contrast, a melanoma of the skin may remain so small that it eludes detection and yet it may metastasize to virtually every organ in the body. With most of the common fatal cancers - lung, breast, large intestine, prostate, stomach - the clinical picture tends to be dominated by metastatic rather than by local tumour. It is the metastatic components that are usually responsible for the death of the patient - either by virtue of the sheer mass of tumour present or its location in vital structures such as the lungs, liver or brain. Carcinomas of the head and neck present a n interesting variant in that the major features are local recurrence and infiltration at the site of the primary tumour, and spread to lymph nodes in the neck. Widespread metastases are not common. The pathology of the spread of carcinomas of the head ,and neck, and the underlying mechanisms involved, are subjects of particular study at the Royal Marsden Hospital and Institute of Cancer Research. In this account we illustrate some features which are likely to be of interest to medical and paramedical teachers.
The anatomy of this region is complicated and the exact location of the primary tumour is an important determinant of its mode and extent of spread. The precise site of the tumour also has major implications for treatment and, ultimately, prognosis. Most carcinomas in this region develop from the normal lining squamous epithelium. Figure 2 shows the edge of a tumour (Ca) which has developed from the squamous epithelium Qf the anterior two thirds of the tongue (T). The tumour has ulcerated superficially (asterisk) and is infiltrating downwards (arrows) into the underlying connective tissue and lingual musculature. x 48.
Infiltration of local soft tissues
Nasal sinuses 3%
-
Mouth comprising lips, buccal mucosa, tongue, floor of mouth, alveolus, oropharynx Larynx, laryngopharynx Nasal sinuses. nasopharynx, nasal cavity
I
The dangerous capacity of head and neck carcinomas to spread in adjacent soft tissues has already been noted.
Figure 1.
Figure 2.
The Primary Tumour Figure 1. Carcinomas can arise at several sites within the head and neck. ~~
~~
R. L. Carter, MA, DM. DSC. FRCPath. is Pathologist at the Institute of Cancer Raearch and Honorary Consultant Pathologist at the Royal Marsden Hospital, London and Sutton. K. G. Moreman, FIIP. FRPS, AIMBI. is Director of Photographic Services, at the Institute of Cancer Research andat the Royal Marsden Hospital.
156
Carter and Moreman
Figure 3 is a carcinoma from the posterior one-third of the tongue. The tumour initially responded to treatment. It then recurred, and a diffusely infiltrating growth was found. x 192. Figure 4 is a poorly differentiated carcinoma from the oropharynx. A different pattern is illustrated; recurrent tumour (Ca) spreads in an ‘Indian file’ arrangement through dense fibrous tissues. x 192.
Direct infiltration of bone
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Figure 5 illustrates direct invasion and
destruction of the mandible by a carcinoma arising from the lower alveolus and floor of the mouth. There is a pathological fracture (arrow), involving the full thickness of the right mandible - i.e. about 3 to 4 cm of solid bone. Figure 6 shows the tumour from the same case. Bone trabeculae (B) are infiltrated by clumps of well differentiated squamous carcinoma (Ca). x 218. Figure 7 is a section from a mandible invaded by another squamous carcinoma arising in the floor of the mouth. Appearances are quite different from figure 6. Bone trabeculae (B) are being destroyed by multinucleated osteoclasts (0),lying well in front of the advancing edge of the carcinoma (Ca). Osteoclasts are normal components of bone, concerned with the physiological process of continuous bone remodelling. Recent work suggests that tumour cells may activate osteoclasts, probably by releasing chemical factors. Osteoclastic activation facilitates invasion
Figure 3. Figure 4.
Figure 5.
The Journal of A udiovisual Media in Medicine
157
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Figure 6.
Figure 8.
158 Figure 7.
Figure 9.
Carter and Moreman
of bone by tumour, particularly during the early stage of the process. There-
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
after, tumour cell invasion continues and the osteoclasts disappear. (cf Figure 6). x 218.
Infiltration of perineural spaces Figure 8. Infiltration of nerves by tumour is often apparent clinically. Most commonly, there is a history of referred pain or a region of numbness or anaesthesia which, by careful mapping, can be shown to correspond with the anatomical distribution of particular nerves. This figure illustrates the sensory defect in a patient with carcinoma of the lower alveolus which invaded the perineural spaces of the inferior dental nerve within the mandible. Figure 9. Spread of carcinova cells (Ca) in perineural spaces, encircling the nerve bundles (N). An uninvolved nerve is seen on the right of the picture. x 19. Figure 10. High power view of carcinoma cells (Ca) encircling the nerve (N) in the perineural spaces. x 209. Tumour cells can track considerable distances in these spaces and eventually gain access to the intracranial cavity. Although the tumour tends to remain at the edge of the nerve, showing little inward invasion, considerable damage is sustained by the nerve fibres. Infiltration of local lymphatics; cervical node metastases Figure 11. Anaplastic carcinoma of the nasopharynx, with tumour cells (Ca) within large, dilated lymphatic vessels (LV). x 191. Infiltration of tumour into the local lymphatic system is the single most important mode of spread. Once the lymphatics are involved, the clinical management becomes more difficult and the prognosis worsens. Figures 12, 13. Replacement of cervical lymph nodes in squamous carcinoma of the larynx. When squamous carcinoma cells (Ca) reach a lymph node, they localize first in the outer part (the subcapsular sinuses) - Figure 12; other regions of the node are intact. Tumour cells subsequently grow and replace all normal structures (Figure 13) and then, very characteristically, they penetrate the lymph node capsule and infiltrate locally in perinodel connective tissues. Though this is not specific to squamous carcinomas, this capacity to breach lymph node capsules is a distinctive (and ominous) feature. Figure 12 x 191, Figure 13 x 217.
Figure ”*
Figure 12. Figure 13.
The Journal of Audiovisual Media in Medicine
159
Primary carcinoma
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Lymph nodes replaced by metastatic carclnoma
Figure 14.
1)
Lymph nodes replaced by metastatic carclnoma; turnour has spread through the lymph node capsule into surrounding tlssues
0
Lymph nodes free of metastatic carctnoma
Figure 14 The normal patterns of lymphatic drainage in the head and neck are complicated with 60 to 80 cervical lymph nodes on each side, each discretely arranged group tending to drain a particular area preferentially. This figure illustrates the general pattern of lymph node involvement in a patient with squamous carcinoma of the middle third of the tongue, treated by radiotherapy and chemotherapy followed by radical surgery. Note the perinodal spread of tumour. With advanced disease, lymph node involvement may occur in the thorax, axilla or abdomen. Metastases in distant organs, such as the lung, may also be lymph-borne, though such sites are more often invaded by tumour cells disseminating in the blood stream.
Infiltration of local
blood vessels
Figure 15. Figure 16.
The vascular system provides a major route for general dissemination of tumour cells giving rise to metastases at distant sites such as the lungs, liver, bones and skin. Figure 15, 16 illustrate venous invasion in squarnous carcinoma of the larynx a small venule (Figure 15) and the internal jugular vein (Figure 16) Figure 15 shows a clump of carcinoma cells (Ca) in the lumen of the vessel; the internal elastic lamina has been 'breached (arrows). x 43. Figure 16. A large mass of carcinoma cells (Ca) fills the lumen of the internal jugular vein. There is pronounced f r a g mentation of the elastic coat (E).x 193. Elastic fibres are exceedingly tough, and the damage seen in these pictures emphasizes the remarkable invasive capacity of squamous carcinomas.
Acknowledgements
We are indebted to members of the Head and Neck Unit, Royal Marsden Hospital, for access to pathological material; to Mr N. S. B. Tanner, FRCS, for figures 1 and 5; and to Robert Thornton, Medical Art Department, Royal Marsden Hospital, for preparing figures 1,lO and 14.
160
Cater and Moreman
Patterns of spread in carcinoma of the head and neck- a pictorial essay
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
R . L. CARTER and K. G.MOREMAN The cardinal feature of malignant tumours is their capacity to invade locally and spread to distant sites, a process known as metastasis. It is important to recognize that the extent of invasion and metastasis varies with different tumours arising at different sites. Cerebral gliomas. for example, are invasive within the central nervous system but metastatic spread outside the craniospinal cavity is exceptional. In contrast, a melanoma of the skin may remain so small that it eludes detection and yet it may metastasize to virtually every organ in the body. With most of the common fatal cancers - lung, breast, large intestine, prostate, stomach - the clinical picture tends to be dominated by metastatic rather than by local tumour. It is the metastatic components that are usually responsible for the death of the patient - either by virtue of the sheer mass of tumour present or its location in vital structures such as the lungs, liver or brain. Carcinomas of the head and neck present a n interesting variant in that the major features are local recurrence and infiltration at the site of the primary tumour, and spread to lymph nodes in the neck. Widespread metastases are not common. The pathology of the spread of carcinomas of the head ,and neck, and the underlying mechanisms involved, are subjects of particular study at the Royal Marsden Hospital and Institute of Cancer Research. In this account we illustrate some features which are likely to be of interest to medical and paramedical teachers.
The anatomy of this region is complicated and the exact location of the primary tumour is an important determinant of its mode and extent of spread. The precise site of the tumour also has major implications for treatment and, ultimately, prognosis. Most carcinomas in this region develop from the normal lining squamous epithelium. Figure 2 shows the edge of a tumour (Ca) which has developed from the squamous epithelium Qf the anterior two thirds of the tongue (T). The tumour has ulcerated superficially (asterisk) and is infiltrating downwards (arrows) into the underlying connective tissue and lingual musculature. x 48.
Infiltration of local soft tissues
Nasal sinuses 3%
-
Mouth comprising lips, buccal mucosa, tongue, floor of mouth, alveolus, oropharynx Larynx, laryngopharynx Nasal sinuses. nasopharynx, nasal cavity
I
The dangerous capacity of head and neck carcinomas to spread in adjacent soft tissues has already been noted.
Figure 1.
Figure 2.
The Primary Tumour Figure 1. Carcinomas can arise at several sites within the head and neck. ~~
~~
R. L. Carter, MA, DM. DSC. FRCPath. is Pathologist at the Institute of Cancer Raearch and Honorary Consultant Pathologist at the Royal Marsden Hospital, London and Sutton. K. G. Moreman, FIIP. FRPS, AIMBI. is Director of Photographic Services, at the Institute of Cancer Research andat the Royal Marsden Hospital.
156
Carter and Moreman
Figure 3 is a carcinoma from the posterior one-third of the tongue. The tumour initially responded to treatment. It then recurred, and a diffusely infiltrating growth was found. x 192. Figure 4 is a poorly differentiated carcinoma from the oropharynx. A different pattern is illustrated; recurrent tumour (Ca) spreads in an ‘Indian file’ arrangement through dense fibrous tissues. x 192.
Direct infiltration of bone
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Figure 5 illustrates direct invasion and
destruction of the mandible by a carcinoma arising from the lower alveolus and floor of the mouth. There is a pathological fracture (arrow), involving the full thickness of the right mandible - i.e. about 3 to 4 cm of solid bone. Figure 6 shows the tumour from the same case. Bone trabeculae (B) are infiltrated by clumps of well differentiated squamous carcinoma (Ca). x 218. Figure 7 is a section from a mandible invaded by another squamous carcinoma arising in the floor of the mouth. Appearances are quite different from figure 6. Bone trabeculae (B) are being destroyed by multinucleated osteoclasts (0),lying well in front of the advancing edge of the carcinoma (Ca). Osteoclasts are normal components of bone, concerned with the physiological process of continuous bone remodelling. Recent work suggests that tumour cells may activate osteoclasts, probably by releasing chemical factors. Osteoclastic activation facilitates invasion
Figure 3. Figure 4.
Figure 5.
The Journal of A udiovisual Media in Medicine
157
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Figure 6.
Figure 8.
158 Figure 7.
Figure 9.
Carter and Moreman
of bone by tumour, particularly during the early stage of the process. There-
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
after, tumour cell invasion continues and the osteoclasts disappear. (cf Figure 6). x 218.
Infiltration of perineural spaces Figure 8. Infiltration of nerves by tumour is often apparent clinically. Most commonly, there is a history of referred pain or a region of numbness or anaesthesia which, by careful mapping, can be shown to correspond with the anatomical distribution of particular nerves. This figure illustrates the sensory defect in a patient with carcinoma of the lower alveolus which invaded the perineural spaces of the inferior dental nerve within the mandible. Figure 9. Spread of carcinova cells (Ca) in perineural spaces, encircling the nerve bundles (N). An uninvolved nerve is seen on the right of the picture. x 19. Figure 10. High power view of carcinoma cells (Ca) encircling the nerve (N) in the perineural spaces. x 209. Tumour cells can track considerable distances in these spaces and eventually gain access to the intracranial cavity. Although the tumour tends to remain at the edge of the nerve, showing little inward invasion, considerable damage is sustained by the nerve fibres. Infiltration of local lymphatics; cervical node metastases Figure 11. Anaplastic carcinoma of the nasopharynx, with tumour cells (Ca) within large, dilated lymphatic vessels (LV). x 191. Infiltration of tumour into the local lymphatic system is the single most important mode of spread. Once the lymphatics are involved, the clinical management becomes more difficult and the prognosis worsens. Figures 12, 13. Replacement of cervical lymph nodes in squamous carcinoma of the larynx. When squamous carcinoma cells (Ca) reach a lymph node, they localize first in the outer part (the subcapsular sinuses) - Figure 12; other regions of the node are intact. Tumour cells subsequently grow and replace all normal structures (Figure 13) and then, very characteristically, they penetrate the lymph node capsule and infiltrate locally in perinodel connective tissues. Though this is not specific to squamous carcinomas, this capacity to breach lymph node capsules is a distinctive (and ominous) feature. Figure 12 x 191, Figure 13 x 217.
Figure ”*
Figure 12. Figure 13.
The Journal of Audiovisual Media in Medicine
159
Primary carcinoma
J Vis Commun Med Downloaded from informahealthcare.com by McMaster University on 01/09/15 For personal use only.
Lymph nodes replaced by metastatic carclnoma
Figure 14.
1)
Lymph nodes replaced by metastatic carclnoma; turnour has spread through the lymph node capsule into surrounding tlssues
0
Lymph nodes free of metastatic carctnoma
Figure 14 The normal patterns of lymphatic drainage in the head and neck are complicated with 60 to 80 cervical lymph nodes on each side, each discretely arranged group tending to drain a particular area preferentially. This figure illustrates the general pattern of lymph node involvement in a patient with squamous carcinoma of the middle third of the tongue, treated by radiotherapy and chemotherapy followed by radical surgery. Note the perinodal spread of tumour. With advanced disease, lymph node involvement may occur in the thorax, axilla or abdomen. Metastases in distant organs, such as the lung, may also be lymph-borne, though such sites are more often invaded by tumour cells disseminating in the blood stream.
Infiltration of local
blood vessels
Figure 15. Figure 16.
The vascular system provides a major route for general dissemination of tumour cells giving rise to metastases at distant sites such as the lungs, liver, bones and skin. Figure 15, 16 illustrate venous invasion in squarnous carcinoma of the larynx a small venule (Figure 15) and the internal jugular vein (Figure 16) Figure 15 shows a clump of carcinoma cells (Ca) in the lumen of the vessel; the internal elastic lamina has been 'breached (arrows). x 43. Figure 16. A large mass of carcinoma cells (Ca) fills the lumen of the internal jugular vein. There is pronounced f r a g mentation of the elastic coat (E).x 193. Elastic fibres are exceedingly tough, and the damage seen in these pictures emphasizes the remarkable invasive capacity of squamous carcinomas.
Acknowledgements
We are indebted to members of the Head and Neck Unit, Royal Marsden Hospital, for access to pathological material; to Mr N. S. B. Tanner, FRCS, for figures 1 and 5; and to Robert Thornton, Medical Art Department, Royal Marsden Hospital, for preparing figures 1,lO and 14.
160
Cater and Moreman
