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TimoAtula

AnttiMäkitie

Cancers of the Head and Neck

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 risk of these cancers is significantly increased by excessive smoking and alcohol abuse. However, not all patients have recognisable risk factors. The occurrence of oropharyngeal cancers related to HPV infections has significantly increased.
Early diagnosis is of vital importance as regards treatment and prognosis.
Over 90% of these cancers are squamous cell carcinomas.
A lump in the neck may also be the first sign of a lymphoma or a thyroid tumour (see A Lump in the Neck).

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.

Either punch or scalpel biopsy may 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, without waiting for the biopsy result.
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.

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 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 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).

At the early stage there are few or no symptoms; only a local change. Hoarseness or mucosal ulcer may, however, occur.
Large tumours may in some patients cause pain as well as difficulty swallowing or breathing.
The first sign is often a lump in the neck.
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 that suggests cancer (see below) for more than 3 weeks, he/she must be referred to specialized care.

The clinical findings may include a sore, an exophytic lesion or only a fixed discoloured blotch (picture 1).
In an adult, a malignant neoplasm of a tonsil may manifest itself as unilateral, prolonged or recurrent tonsillitis.
Asymmetry of the tonsillar region without symptoms of an infection.
Two different groups of tonsil (oropharynx) cancer exist: HPV-related disease and cancer not related to 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.

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.

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.
Dyspnoea is a late sign.

Usually 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).
Surgery will confirm diagnosis.

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 5 years. Some salivary gland cancers will warrant a longer follow-up. An appointment every 3-4 months for 3 years, and every 6 months thereafter. The follow-up should usually be carried out by the specialist physician.
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.

For pharmacological management of cancer pain and other palliative care, see Pharmacological Treatment of Cancer Pain and Palliative Treatment.
Tracheostomy should be formed early if the tumour and swelling threaten to occlude the airways.
A PEG tube is sometimes indicated if swallowing is affected.