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TimoAtula
AnttiMäkitie

Cancers of the Head and Neck

Essentials

  • This group consists of cancers of the oral cavity, different parts of the pharynx, larynx, nose and paranasal sinuses, as well as salivary glands. Only the most important types are discussed below.
  • The occurrence of oropharyngeal cancers associated with HPV infections has significantly increased.
  • A lump in the neck may also be the first sign of a lymphoma or a thyroid tumour (see A Lump in the Neck).
  • Early diagnosis is of vital importance as regards treatment and prognosis.
  • If a patient has had a symptom or finding suggestive of cancer of the head and neck for 3 weeks, he/she should be referred to specialized care for an assessment without delay.

General remarks

  • Over 90% of these cancers are squamous cell carcinomas.
  • The risk of these cancers is significantly increased by smoking and heavy alcohol consumption. However, not all patients have recognizable risk factors.
  • HPV infection is associated with cancers of the oropharynx (palatine tonsils and root of the tongue). In practice, p16 staining is used: p16 positive cancers are typically associated with an HPV infection.
  • HPV-associated cancers have a better prognosis than other cancers.
  • The treatment takes place in specialized centres.

Precursor stages

  • Leukoplakia Assessment of Oral Mucosal Changes is a white uniform mucosal lesion that cannot be easily scraped off. A small number of these lesions undergo malignant change.
  • Erythroplakia Assessment of Oral Mucosal Changes is a reddish mucosal lesion that carries a high risk of malignant transformation.
  • Treatment consists of excision whenever possible. Extensive lesions should be monitored by photographing e.g. every 6 or 12 months and checked, as necessary, with biopsies.

Biopsies and other investigations Screening Programmes for the Early Detection and Prevention of Oral Cancer

  • Either punch or scalpel biopsy can be taken of an oral or pharyngeal lesion. If the patient has a finding that clearly suggests cancer, he/she should be, in order to avoid delays in acquiring treatment, referred to urgent specialized care and the sampling and other examinations should be done at specialized care
  • Sometimes the biopsy is falsely interpreted as benign. If the lesion is clinically clearly suspicious, the patient must be referred to a specialist physician regardless of the biopsy result.
  • If the patient presents with a lump in the neck with no other symptoms, a thorough ear, nose and throat examination is initially performed, and if nothing else suggests a neoplasm, an ultrasound examination and a fine needle biopsy are carried out (see A Lump in the Neck).
  • If the finding is something else than a clinically clear inflammatory lump the patient should be referred to a specialist for assessment regardless of the fine needle biopsy result.
  • Imaging studies are selected within specialized care on a case by case basis.
  • Ultrasound imaging combined with a needle biopsy (fine- or core-needle biopsy) is the primary examination for parotid gland and thyroid gland examination. If the cause of the lump in the neck is compatible to be a metastasis and a primary tumour is found, these examinations are not usually performed.

Treatment principles

  • Avoidance of risk factors (smoking, alcohol), also as a preventive measure
  • The treatment of small and local cancers usually consists of surgery, except in laryngeal cancers where radiotherapy may be used as an alternative. In hypopharyngeal and nasopharyngeal cancers, a combination of radiotherapy and cytotoxic chemotherapy is possible.
  • In more extensive cancers, surgery is combined with radiotherapy. Cytotoxic chemotherapy is also often indicated as an adjunct to radiotherapy, the condition of the patient allowing. Certain cancers, such as p16-positive cancer of the root of the tongue and palatine tonsils, are increasingly treated with definitive (chemo)radiotherapy.
  • Before the oncological treatment is started, a thorough dental examination and treatment is carried out, and, if needed, insertion of a gastrostoma (PEG tube) is considered to ensure sufficient nutrition.
  • Due to the possibility of micrometastases, the neck area is often treated even in the absence of abnormal lymph nodes.
  • In connection with surgery of larger tumours, a reconstruction may be performed with the aid of a free vascularized tissue graft from, for example, the thigh, forearm or hip.
  • Treatment consisting only of radiotherapy and chemotherapy is often attempted for the management of extensive tumours of the larynx and pharynx in cases where surgery would significantly affect the quality of life (e.g. laryngectomy).

Signs, symptoms and special features

Shared symptoms

  • At the early stage there are few or no symptoms; only a local change. Hoarseness or mucosal ulcer may, however, occur.
  • The first sign is often a lump in the neck.
  • Large tumours may cause pain as well as difficulty swallowing or breathing.
  • Generalised symptoms are usually indicative of a different illness or advanced cancer.
  • Bleeding always warrants further investigation. Bleeding is not common in the early stages.
  • If the patient has a symptom or finding that suggests cancer (see below) for more than 3 weeks, he/she must be referred to specialized care.

Cancer of the lip

  • A scab or a sore
  • Usually has a good prognosis.

Oral cavity and oropharynx

  • The clinical findings may include a sore, an exophytic lesion or only a pale mucosal lesion (picture 1).
  • In an adult, a malignant neoplasm of a tonsil may manifest itself as unilateral prolonged tonsillitis.
  • Asymmetry of the tonsillar region without symptoms of an infection.
  • Two different groups of oropharyngeal (palatine tonsil and root of the tongue) cancer exist: HPV-associated disease and cancer not associated with HPV.
  • In the diagnostics and TNM staging of oropharyngeal cancer, the disease groups are distinguished by 16 staining, which quite well reflects the presence of HPV in the cancer.

Nose and nasopharynx

  • Symptoms
    • Recurrent epistaxis
    • Nasal unilateral stuffiness
    • Unilateral sinusitis that is slow to improve
    • Adult-onset ear infections, especially glue ear
    • In nasopharyngeal cancer a metastasis in the neck often is the initial symptom.

Hypopharynx

  • Symptoms
    • Pain on swallowing, may radiate to the ear
    • Dysphagia
    • Sensation of a lump
  • Usually a poor prognosis
  • Patients complaining of pharyngeal pain, in particular, should be referred to a specialist in otorhinolaryngology.

Larynx

  • The first sign of vocal cord cancer is often prolonged hoarseness.
  • If the cancer originates from the region above the vocal cords the patient will complain of a sensation of a lump.
  • A wheeze during inspiration may be caused by the narrowing of the larynx and, in association with cancer, it is a sign of advanced disease.
  • Dyspnoea is a late sign.

Major salivary glands

  • Usually only a symptomless lump
  • A fine-needle biopsy is important, but the possibility of misdiagnosis must be borne in mind (see A Lump in the Neck).
  • Even with imaging, it is not possible to distinguish with certainty between a benign and a malignant tumour.
  • Diagnosis will be confirmed only after surgery in a pathologist's assessment.

Follow-up

  • The majority of recurrences of squamous cell carcinoma will occur within 2-3 years.
  • The average five-year survival rate is about 50%, but may even be over 90% in the case of small, local tumours.
  • A follow-up examination should concentrate particularly on the tumour site, its surrounding area and the neck lymph nodes since these are the most likely sites of a recurrence.
  • Imaging studies, only when considered necessary
  • Depending on the disease, routine clinical follow-up usually lasts for 3 years. Some salivary gland cancers will warrant a longer follow-up; in the beginning an appointment every 3-4 months, and later every 6 months. The follow-up takes place in specialized care.
  • The patients will have an increased risk of another cancer, especially around the head and neck region, lungs or oesophagus. All new symptoms merit early investigation.
  • Enhanced oral and dental hygiene is recommended after radiotherapy due to the risk of osteoradionecrosis.

Palliative care

    References

    • Finnish Society for Head and Neck Oncology. http://www.fshno.fi.
    • [Oral cancer]. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim and the Finnish Dental Society Apollonia. Helsinki: Finnish Medical Society Duodecim, 2019 (accessed 5 Jul 2023). Available in Finnish at .