HEAD & NECK TUMOURS

Introduction;
Common non-cutaneous tumour of the head and neck include;
 Squamous cell carcinoma of the larynx
 Squamous cell carcinomas of the tongue
 Palatine tonsil
 Floor of the mouth
 Salivary glands
 Jaw
 Nose
 Paranasal sinuses
 Ear
 Thyroid gland
 Eye
 Skin
 Excluding the skin and thyroid gland, > 90% of head and neck cancers are
squamous cell carcinomas

 5% are melanomas, lymphomas, and sarcomas

 Patients with sarcomas or carcinomas of the salivary glands or paranasal

sinuses are often younger than patients with squamous cell carcinoma, who
are more commonly in their mid-50s and older.
 Etiology;

 85% or more, with cancer of the head and neck have a history of alcohol
use, smoking, or both.
 Other suspected causes include;
 Snuff or chewing tobacco
 Sunlight exposure
 Previous x-rays of the head and neck
 Certain viral infections e.g. HPV, Epstein-Barr virus
 Ill-fitting dental appliances
 Chronic candidiasis
 Poor oral hygiene
 Symptoms and Signs;

 Asymptomatic neck mass

 Painful mucosal ulceration
 Visible mucosal lesion (eg, leukoplakia, erythroplakia)
 Pain
 Paresthesia
 Nerve palsies
 Trismus
 Halitosis
 Otalgia is an often overlooked symptom usually representing referred pain
from the primary tumor
 Weight loss caused by perturbed eating
 Odynophagia is also common.
 Diagnosis
 Routine physical examination (including a thorough oral examination) is the
best way to detect cancers early before they become symptomatic.
 Commercially available brush biopsy kits help screen for oral cancers.
 Any head and neck symptom (eg, sore throat, hoarseness, otalgia) lasting >
2 to 3 wk should prompt referral to a head and neck specialist.
Definitive diagnosis usually requires a biopsy. Additional important
information is obtained from a combination of imaging tests (eg, CT, MRI,
PET/CT), endoscopy, and fine-needle aspiration of any neck mass.
 Staging

Head and neck cancers may remain localized for months to years. Local tissue
invasion eventually is followed by metastasis to regional lymph nodes, related
in large part to tumor size and extent, and reduces overall survival by nearly
half. Distant metastases tend to occur late, usually in patients with advanced
tumor and nodal stages. Metastases occur more commonly among
immunocompromised patients. Common sites of distant metastases are the
lungs, liver, bone, and brain.
Head and neck cancers are staged (see Table 1:
Tumors of the Head and Neck: Staging of Head and Neck Cancer ) according to
size and site of the primary tumor (T), number and size of metastases to the
cervical lymph nodes (N), and evidence of distant metastases (M). Staging
usually requires imaging with CT, MRI, or both, and often PET.
Staging of Head and Neck Cancer
Stage Tumor (Maximum Penetration) Regional Lymph Node Metastasis Distant Metastasis

I T1 N0 M0

II T2 N0 M0

III T3 or N0 M0

  T1-3 N1 M0

IVA T1-3 N2 M0

  T4a N0-2 M0

IVB T4b Any N M0

  Any T N3 M0

  Any T Any N M1

IVC

TNM classification:

T1 ≤ 2 cm in greatest dimension;
T2 = 2–4 cm or affects 2 areas within a specific site;
T3 > 4 cm or affects 3 areas within a specific site;
T4 = invades specific structures (4a is resectable and 4b is unresectable).
N0 = none; N1 = one node ≤ 3 cm; N2 = node between 3 and 6 cm or multiple nodes; N3 = node > 6 cm.

M0 = none; M1 = present.
 Prognosis
Prognosis is favorable if diagnosis is early and treatment is timely and appropriate.
In general, the more poorly differentiated the cancer, the greater the chance of
regional and distant metastases. The presence of regional nodal spread reduces
overall survival by nearly half. Distant metastasis greatly reduces survival, having
only rare cures. Local invasion, a criterion for advanced T stage, with invasion of
muscle, bone, or cartilage, also significantly decreases cure rate. Perineural spread,
as evidenced by pain, paralysis, or numbness, indicates a highly aggressive tumor,
is associated with nodal metastasis, and has a less favorable prognosis than a
similar lesion without perineural invasion.
With appropriate treatment, 5-yr survival can be as high as 90% for stage I, 75 to
80% for stage II, 45 to 75% for stage III, and up to 40% for stage IV. The survival
rates vary greatly depending on the primary site. Stage I laryngeal cancers have an
excellent survival rate when compared to other sites.
 Treatment
Many stage I tumors, regardless of location, respond similarly to surgery
and to radiation therapy, allowing other factors (eg, patient preference) to
determine choice of therapy. Thus, the treating physician should carefully
review risks and benefits with the patient. However, at certain locations,
there is clear superiority of one modality over another. For example,
surgery is the better treatment for early-stage disease involving the oral
cavity. In select head and neck cancers, endoscopic surgery has cure
rates similar to those of open surgery or radiation, and morbidity is
significantly less. However, many physicians still recommend radiation
for early-stage laryngeal cancer.
If radiation therapy is chosen for primary therapy, it is delivered to the
primary site and sometimes bilaterally to the cervical lymph nodes. The
treatment of lymphatics, whether by radiation or surgery, is determined
by the primary site, histologic criteria, and risk of nodal disease.
Advanced-stage disease (stages III and IV) often requires multimodality
treatment, incorporating some combination of chemotherapy, radiation
therapy, and surgery. Bone or cartilage invasion requires surgical resection
of the primary site and usually regional lymph nodes because of the high risk
of nodal spread. If the primary site is treated surgically, then postoperative
radiation to the cervical lymph nodes is delivered if there are high-risk
features, such as multiple lymph nodes with cancer or extracapsular
extension. Postoperative radiation usually is preferred over preoperative
radiation, because radiated tissues heal poorly. Recent studies have shown
that adding chemotherapy to adjuvant radiation therapy to the neck improves
regional control of the cancer and improves survival. There are significant
risks to this approach, so the decision to add chemotherapy should be
carefully considered.
Primary chemotherapy is reserved for chemosensitive tumors, such as
Burkitt's lymphoma, or for patients who have widespread metastases (eg,
hepatic or pulmonary involvement). Several drugs— cisplatin
PLATINOL
, fluorouracil
ADRUCIL
Click for Drug Monograph
, bleomycin
BLENOXANE
Click for Drug Monograph
, and methotrexate
RHEUMATREX
Click for Drug Monograph
—provide palliation for pain and shrink the tumor in patients who cannot be
treated with other methods. Response may be good initially but is not
durable, and the cancer will return.
Tumor recurrence:
Managing recurrent tumors after therapy is complex and has potential
complications. A palpable mass or ulcerated lesion with edema or pain at the
primary site after therapy strongly suggests a persistent tumor. Such patients
require CT (with thin cuts) or MRI. For local recurrence after surgical
treatment, all scar planes and reconstructive flaps are excised along with
residual cancer. Radiation therapy, chemotherapy, or both may be done but
have limited effectiveness. Patients with recurrence after radiation therapy
should not receive additional radiation and are best treated with surgery.
Symptom control:
Pain is a common symptom in patients with head and neck cancer and must
be adequately addressed. Palliative surgery or radiation may temporarily
alleviate pain, and in 30 to 50% of patients, chemotherapy can produce
improvement that lasts a mean of 3 mo. A stepwise approach to pain
management, as recommended by the WHO, is critical to controlling pain.
Severe pain is best managed in association with a pain and palliative care
specialist.
Pain, difficulty eating, choking on secretions, and other problems make
adequate symptomatic treatment essential. Patient directives regarding such
care should be clarified early.
Adverse effects of treatment:
All cancer treatments have potential complications and expected sequelae. Because
many treatments have similar cure rates, the choice of modality is based largely on real,
or perceived, differences in sequelae.
Toxic effects of chemotherapy include malaise, severe nausea and vomiting, mucositis,
transient hair loss, gastroenteritis, hematopoietic and immune suppression, and
infection.
Therapeutic radiation for head and neck cancers has several undesirable adverse
effects. The function of any salivary gland within the beam is permanently destroyed by
a dose of about 40 Gy, resulting in xerostomia, which markedly increases the risk of
dental caries. Newer radiation techniques, such as intensity-modulated radiation
therapy, can minimize or eliminate toxic doses to the parotid glands in certain patients.
Radioprotectant drugs (eg, amifostine) also can help protect salivary function. In
addition, the blood supply of bone, particularly in the mandible, is compromised by
doses of > 60 Gy, and osteoradionecrosis may occur (see also Approach to the Dental
Patient: Radiation Therapy). In this condition, tooth extraction sites break down,
sloughing bone and soft tissue. Therefore, any needed dental treatment, including
scaling, fillings, and extractions, should be done before radiation therapy. Any teeth in
poor condition that cannot be rehabilitated should be extracted. Radiation therapy may
also cause oral mucositis and dermatitis in the overlying skin, which may result in
dermal fibrosis. Loss of taste (ageusia) and impaired smell (dysosmia) often occur but
are usually transient.
 Prevention
Removing risk factors is critical, and all patients should cease
tobacco use and limit alcohol consumption. Removing risk factors
also helps prevent disease recurrence in those treated for cancer. A
new primary cancer develops in about 5% of patients/yr (to a
maximum risk of about 20%); risk is lower in those who stop.
Cancer of the lower lip may be prevented by sunscreen use and
tobacco cessation. Because 60% of head and neck cancers are well
advanced (stage III or IV) at the time of diagnosis, the most promising
strategy for reducing morbidity and mortality is diligent routine
examination of the oral cavity.