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22.4 Head and Neck Cancers

Table of Contents

Cancer of the head and neck include the following:

The oral cavity, pharynx, larynx, nasal cavity, para nasal sinuses, salivary glands, and thyroid. In Tanzania there is no national prevalence data about head and neck cancers but data available at ORCI shows that they contribute about 7% of all cancers. These tumours may present with a neck mass due to lymph node metastases, with or without findings from the primary disease site. Important etiological factors are smoking, excessive alcohol, viral infections (eg HPV and EBV), genetic predisposition, previous exposure to radiation and industrial chemicals. Squamous cell carcinoma is the commonest histological type for the malignancies but salivary gland tumors are mostly adenocarcinoma

22.4.1 Nasopharyngeal Cancer

Nasopharyngeal carcinoma is the predominant tumor type arising in the epithelium of the nasopharynx

Diagnostic Criteria

  • Neck mass, unilateral hearing loss, tinnitus, nasal obstruction, epistaxis, and cranial nerve palsies

Investigations:

  • FBC, RFT, LFT, HIV
  • Chest X-ray
  • Abdominal ultrasound
  • CT scan and/or MRI of the nasopharynx, skull base, and neck
  • Nasopharyngoscopy
  • Endoscopic guided biopsy of the primary tumor for histology
  • Pet CT may be required if available
  • Immunohistochemistry may be needed to further confirm the diagnosis

Staging: TNM staging system

Management

Due to deep location of nasopharynx, and anatomic proximity to critical structures, radical surgery is typically not possible. Nasopharyngeal cancer is mainly treated by radiotherapy either alone or in combination with chemotherapy.

Stage Management
Stage I Radiotherapy alone to primary disease and neck
Stage II–IVB Concurrent chemotherapy and radiation to the primary disease and neck
Stage IVC palliative care (which may include chemotherapy and radiotherapy)
Induction chemotherapy can be considered for stage III– IVB if delays are anticipated in initiation of concurrent chemotherapy and radiation.
Local recurrence Chemotherapy, surgery or re-irradiation

22.4.2 Laryngeal Cancer

Laryngeal cancer is one of the most common cancers of head and neck. It is predominantly found in men and mostly in those with history of tobacco smoking and alcohol intake. It is divided into three major anatomic regions; supraglottis, glottis and subglottic.

Diagnostic Criteria

  • Hoarseness, stridor, difficulty in breathing, neck mass, odynophagia, cough

Investigations:

  • FPC, RFT, LFT
  • Chest X-ray
  • CT scan and/or MRI of the neck
  • Laryngoscopy
  • Pathology: Definitive diagnosis is confirmed by laryngoscopy-guided biopsy of the primary tumor

Staging: TNM.

Management: General concept

Stage Management
Stage I and II Primary site: Partial or total laryngectomy OR radiotherapy alone.
Stage III–IVB Concurrent chemoradiation or total Laryngectomy and neck dissection followed by adjuvant radiotherapy or chemo radiotherapy
Stage IVC Palliative

22.4.3 Hypopharyngeal Cancers:

Hypopharyngeal cancer includes tumors arising from the pyriform sinus, posterior pharyngeal wall, postcricoid region.It is associated with tobacco use, alcohol consumption, and Plummer–Vinson syndrome. It is mostly seen in patients above 40 years.

Diagnostic Criteria:

  • Dysphagia, odynophagia, change in speech (dysarthria), neck mass, referred otalgia, throat pain, weight loss, sensation of mass in throat and hoarseness of voice.

Investigations

  • FPC, RFT, LFT.History
  • Hypopharyngoscopy and biopsy and biopsy for histopathology
  • Chest X-ray
  • CT scan and/or MRI of the neck

Staging: TNM staging system.

Management

Radiation therapy is the mainstay of first-line local treatment for early stage hypopharyngeal carcinoma. For more advanced disease, concurrent chemoradiation reduces the rate of distant metastasis, and improves local control.

22.4.4 Salivary gland cancer

Salivary gland cancers arise from major or minor salivary glands in the head and neck region. The most common malignant salivary gland tumors are mucoepidermoid carcinoma and adenocarcinoma

Presentation: Depends on primary site involved.

  • Mass, pain, nerve palsies, neck mass

Investigations:

  • FPC, LFT, and RFT
  • Chest X-ray
  • CT scan and/or MRI of head and neck
  • Biopsy of the primary tumor for histology. Imaging reports (CT Scan/MRI of head and neck)

Staging: TNM staging system:

Treatment:

  • Complete surgical resection with adjuvant radiotherapy if adverse features are present
  • If disease is not resectable, definitive radiotherapy or concurrent chemoradiotherapy is indicated
  • Neck dissection is indicated for high-grade tumors or clinically positive neck disease

22.4.5 Nasal Cavity and Paranasal Sinus Cancer

These are tumors arising from nasal cavity and the four paired paranasal sinuses (frontal, ethmoid, maxillary, and sphenoid).

Diagnostic Criteria:

Nasal obstruction, epistaxis, proptosis, double vision, cheek mass, loss of sensation of the cheek and loosening or pain of the teeth

Investigations:

  • FBC, RFT, LFT
  • Chest X-ray
  • Abdominal Ultrasound
  • CT scan and/or MRI of the para nasal sinuses and neck
  • Direct fibre-optic endoscopy
  • Endoscopic guided biopsy of the primary tumor for histopathology

Staging: TNM

Treatment:

  • Treatment is by surgery and or radiotherapy with or without chemotherapy.
  • Surgical resection of the primary tumor and neck dissection followed by radiotherapy can be done in early disease stages. It may also be used for management persistently enlarged lymph nodes, persistent or recurrent disease after radiotherapy.
  • Stage I–IINO: complete surgical resection followed by radiotherapy alternatively definitive radiotherapy.
  • Radiotherapy can be given as an alternative definitive treatment, either alone or in combination with chemotherapy. It is used in palliative care for advanced diseases
  • Chemotherapy is used in induction, concurrent or adjuvant therapy.

22.4.6 Oral Cavity Cancer

Oral cavity consists of the upper and lower lips, gingivobuccal sulcus, buccal mucosa, upper and lower gingiva, retromolar trigone, hard palate, floor of mouth, and anterior two–third of the tongue. Risk factors include smoking, excessive consumption of alcohol, poor oral hygiene, prolonged focal denture irritation, betel nut chewing, and syphilis.

Diagnostic Criteria:

  • Non-healing ulcer, speech difficulty, hypersalivation, neck mass, dysphagia and otalgia

Investigations:

  • FBC, LFT, RFT, HIV test
  • Chest X-ray
  • CT scan and/or MRI of the primary and neck
  • Mirror and fibre-optic endoscopic examination
  • Biopsy for histologic confirmation

Management: Surgery and Radiotherapy

Surgery is the mainstay treatment modality for cancer of the oral cavity. Single modality treatment with surgery or radiation therapy is preferred for early-stage oral cavity cancer. Definitive radiation with concurrent chemotherapy is the current standard for unresectable locally advanced disease. Radiotherapy can be given as palliative treatment to primary or metastatic area. Chemotherapy may also be given as palliative care in a very advanced disease.

22.4.7 Oropharyngeal Cancer

Oropharynx is located between the soft palate superiorly and the hyoid bone inferiorly. The oropharynx has four walls; soft palate, tonsillar region, base of tongue, and pharyngeal wall. It is associated with tobacco use and alcohol consumption and HPV. Tonsillar and pharyngeal tongue tumors frequently are initially recognized by nodal metastases.

Clinical Presentation

  • Sore throat, non-healing oropharyngeal ulcers, dysphagia, referred otalgia, hoarseness (with larynx invasion), odynophagia, hot potato voice and impaired tongue movement, including protrusion.

Investigations and Staging:

  • As for oral cancers

Management:

Oropharyngeal cancers are mainly treated by Radiotherapy in combination with chemotherapy. Surgery can be used in selected cases.

  Note:
Head and neck tumour patients must be referred to cancer specialized centers for evaluation and definitive management.
Curative radiotherapy dose for head and neck cancers is 66–70Gy given at conventional fraction of 1.8–2Gy/f
Follow up visits: 1st visit at 4–6weeks then after each 3–4 months in the 1st year, 6 monthly in the 2nd year thereafter yearly.

22.4.8 Thyroid Carcinoma

These tumours present as ‘goitre’ and can remain silent for decades without any discomfort. There are four main types – papillary, follicular, medullary and anaplastic thyroid cancers

Diagnostic Criteria

  • Thyroid mass, laryngeal nerve palsy, hoarseness, dyspnea, dysphagia

Investigations:

  • Thyroid function tests (T3, T4, TSH), FBC, LFTs, Urea & creatinine, serum calcitonin, serum thyroglobulin levels
  • Thyroid scan, CXR, isotope bone scan, CT scan of the neck, Fine needle aspiration cytology (FNAC) of a thyroid lesion

Treatment:

Surgery is the mainstay of treatment; total or near total thyroidectomy. Radiotherapy is indicated in all cases of anaplastic carcinoma

Pharmacological Treatment

  • Radioactive iodine ablation is indicated in all patients with well differentiated thyroid cancer after surgery
  • Thyroid-stimulating hormone (TSH) suppression therapy (levothyroxine)
    • TSH suppression to < 0.1 mU/L is indicated in intermediate and high–risk disease. TSH maintenance at or slightly below the lower–normal limit (0.3–2 mU/L) may be considered for low-risk disease
    • In patients with persistent disease, the serum TSH should be maintained below 0.1mU=L indefinitely in the absence of specific contraindication
    • In patients who are clinically and biochemically free of disease but who presented with high risk disease, consideration should be given to maintaining TSH suppressive therapy to achieve serum TSH levels of 0.1– 0.5mU=L for 5–10 years.
    • In patients free of disease, especially those at low risk for recurrence, the serum TSH may be Kept within the low normal range (0.3–2mU=L).
    • In patients who have not undergone remnant ablation who are clinically free of disease and have undetectable suppressed serum Thyroglobulin(Tg) and normal neck ultrasound, the serum TSH may be allowed to rise to the low normal range (0.3–2mU=L).

Chemotherapy for anaplastic, recurrent or metastatic cancer

S: Placliataxel IV 175mg/m2 day 1 plus Doxorubicin IV 60mg/m2 day1 every 3 weeks up to 6 cycles.

Note: All patients must be referred to a cancer specialized center for proper management.

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