OVERVIEW

Introduction:

Head and neck cancers are the 6th most common cancer worldwide. They consist of a group of biologically similar cancers originating from the upper aero-digestive tract (UADT), which is an anatomic region comprising of the:



  Nasal Cavity (nose, nasal septum and turbinates)
  Nasopharynx (area posterior to the nasal cavity)
  Paranasal Sinuses (hollow bony spaces centered around the nose)
  Oral Cavity (lip, tongue, jaw, gums, cheek and hard palate)
  Oropharynx (tonsils, soft palate and posterior third of the tongue)
  Hyoppharynx (throat and upper gullet)
  Larynx (voice box)


The majority of head and neck cancers are SQUAMOUS CELL CANCERS (SCC). SCC is strongly associated with lifestyle risk factors, including tobacco and betel nut use, alcohol consumption, and certain strains of the human papillomavirus (HPV) that are sexually transmitted.

In the Asian subcontinent a slightly different cancer, NASOPHARYNGEAL CANCER (NPC), also referred to as "NOSE CANCER", is also very common. Although NPC arises from the UADT, it is distinct from squamous cancers of the UADT in its epidemiology, biology, clinical behavior, and treatment.  (see NASOPHARYNX)

SCC and NPC often spread to the lymph nodes of the neck, and this is may indeed be the first presentation of the disease, a neck lump representing a swollen cancerous lymph node.

Head and neck cancers are curable if detected early, but treatment frequently involves a combination of surgery, radiation therapy and chemotherapy.


Symptoms

Common symptoms associated with head and neck cancers in are:

          A mass or lump in the neck
          Persistent voice change or hoarseness
          Difficult or painful swallowing
          Ear pain (which may represent pain referred from throat cancer)
          Hearing loss, particularly if one-sided
          Persistent nasal congestion or bloody nasal discharge
          A non-healing tongue ulcer, poor healing tooth socket or persistent white or red discoloration within the
           oral cavity


Investigations

Investigations essential for the accurate diagnosis and staging of a head and neck cancer are.

          FIBREOPTIC NASOENDOSCOPY is an endoscopic procedure that is performed in the office under
           local anesthesia. It provides excellent direct visualization of the internal structures of the upper aero-
           digestive tract, particularly of the post-nasal space, throat and voice box.

          TISSUE BIOPSY is a process whereby a small amount of tissue is taken for
           examination under the microscope, or histopathologic analysis. Histopathology is the gold standard by
           which an abnormal growth is confirmed to be cancerous or not.

           Tissue biopsy can be performed in various ways, from a fine needle aspiration biopsy (FNAB), which is a
           simple procedure performed in the office, to an excisional biopsy, a minor surgical procedure by which the
           lump or growth is removed at a day surgery facility.

          DIAGNOSTIC RADIOLOGY are scans performed to provide additional information for accurate
           staging of a suspected cancer. Staging is the process by which the size of the tumor, involvement of critical
           structures or lymph nodes in the vicinity, or spread to regions elsewhere in the body like the lungs, bone or
           liver is determined.

           CT, MRI and PET scans are the most frequently utilized diagnostic scans.


Staging

Accurate staging of a head and neck cancer is essential for determining the appropriate treatment strategy to adopt as well as for the assessment of long-term prognosis.

The American Joint Committee on Cancer / International Union against Cancer (AJCC/UICC) Staging System is the most universally recognized and accepted staging system. It utilizes the TNM Classification of malignant tumors, where

          T represents the size of the TUMOR,
          N determines the absence, presence & number of Lymph NODES involved by cancer
          M denotes evidence of spread elsewhere in the body, called METASTASIS, to organs like the lungs, bone or
           liver


The T, N, and M scores are then pooled together to provide an overall "stage" of the cancer. Cancer stages range from STAGE I through IV.

Stage I & II are referred to as early stage, and Stage III & IV as advanced stage cancer.

Treatment

Advancements in diagnostic imaging, surgical techniques and radiation & chemotherapy delivery have led to improvements survival and in the quality of life for head and neck cancer patients.

Selection for appropriate treatment strategy for a specific cancer depends on a number of key factors including:

          Tumor type, size and site
          Clinical stage
          Relative morbidity of the various treatment options at the specific sites
          Patient performance and nutritional status
          Co-morbid medical conditions (eg. co-existing heart or kidney disease)


Early Stage Cancer (Stage I & II)

Early stage cancers are usually treated with SINGLE MODALITY TREATMENT. This may be in the form of:

          SURGERY

                 or   

          RADIATION THERAPY


Advanced Stage Cancer (Stage Ill & IV)

Advanced cancers usually require MULTIMODALITY TREATMENT. This may be in the form of:

          SUGERY followed by RADIATION THERAPY, with or without CHEMOTHERAPY

                 or

          COMBINED CHEMO-RADIOTHERAPY, with SURGERY as salvage treatment if there is evidence of recurrent
            or residual disease


Prognosis

Early-stage head and neck cancers (Stage I and ll) achieve high cure rates of between 85 - 95%.

More than two thirds of all head and neck cancer patients, unfortunately, present with locally advanced disease. The cure rates for locally advanced disease (Stage Ill and IV) decreases to between 40 - 65%.

Recurrent disease, spread to other organs (metastasis) and new primary cancers are the main cause of morbidity and mortality for head and neck cancers.

The Thyroid Head & Neck Surgery Centre