Head and neck cancer

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Maneesha Nandimandalam, M.B.B.S.[2]

Head and Neck cancer Microchapters

Patient Information

Overview

Classification

Brain tumor
Oral cancer
Nasopharyngeal cancer
Hypopharyngeal cancer
Glomus tumor
Salivary gland tumor
Laryngeal cancer
Thyroid cancer
Parathyroid cancer
Esophageal cancer

Causes

Differential diagnosis


Classification

  • Head and neck cancers comprise of a group of malignancies arising from the oral cavity, pharynx and larynx, paranasal sinuses, nasal cavity or salivary glands with squamous cell carcinoma representing the most common histology.

'Head and neck squamous cell carcinomas (HNSCC's) make up the vast majority of head and neck cancers, and arise from mucosal surfaces throughout this anatomic region. These include tumors of the nasal cavities, paranasal sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.

Oral cavity

Squamous cell cancers are common in the oral cavity, including the inner lip, tongue, floor of mouth, gingivae, and hard palate. Cancers of the oral cavity are strongly associated with tobacco use, especially use of chewing tobacco or "dip", as well as heavy alcohol use. Cancers of this region, particularly the tongue, are more frequently treated with surgery than are other head and neck cancers.

Surgeries for oral cancers include

  • Maxillectomy (can be done with or without Orbital exenteration
  • Mandibulectomy (removal of the mandible or lower jaw or part of it)
  • Glossectomy (tongue removal, can be total, hemi or partial)
  • Radical neck dissection
  • Moh's procedure
  • Combinational e.g. glossectomy and laryngectomy done together.

The defect is covered/improved by using another part of the body and/or skin grafts and/or wearing a prosthesis.

Nasopharynx

Nasopharyngeal cancer arises in the nasopharynx, the region in which the nasal cavities and the Eustachian tubes connect with the upper part of the throat. While some nasopharyngeal cancers are biologically similar to the common HNSCC, "poorly differentiated" nasopharyngeal carcinoma is distinct in its epidemiology, biology, clinical behavior, and treatment, and is treated as a separate disease by many experts.

Surgeries for nasal cancer (cancer of the nose)

  • Surgery to removal the entire nose or part of the nose. Removal of all of the nose is called a total rhinectomy, for part of the nose it is called a partial rhinectomy. Afterwards to cover the defect, a new nose can be made by using another part of the body and/or a nose prosthesis is made.

Oropharynx

Oropharyngeal cancer begins in the oropharynx, the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils. Squamous cell cancers of the tonsils are more strongly associated with human papillomavirus infection than are cancers of other regions of the head and neck.

Hypopharynx

The hypopharynx includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis, and have the most adverse prognoses of pharyngeal tumors. They tend to metastasize early due to the extensive lymphatic network around the larynx.

Larynx

Laryngeal cancer begins in the larynx or "voice box." Cancer may occur on the vocal cords themselves ("glottic" cancer), or on tissues above and below the true cords ("supraglottic" and "subglottic" cancers respectively). Laryngeal cancer is strongly associated with tobacco smoking.

Surgeries can include partial laryngectomy (removal of part of the larynx) and total laryngectomy (removal of the whole larnyx). If the whole larynx has been removed the person is left with a permanent tracheostomy opening and learns to speak again in a new way with the help of intensive teaching and speech therapy and/or an electronic device.

Also anyone who has had a glossectomy (tongue removal) will be taught to speak again in a new way and have intensive speech therapy

Trachea

Cancer of the trachea is a rare malignancy which can be biologically similar in many ways to head and neck cancer, and is sometimes classified as such.

Most tumors of the salivary glands differ from the common carcinomas of the head and neck in etiology, histopathology, clinical presentation, and therapy, Other uncommon tumors arising in the head and neck include teratomas, adenocarcinomas, adenoid cystic carcinomas, and mucoepidermoid carcinomas. Rarer still are melanomas and lymphomas of the upper aerodigestive tract.

[1][2][3][4]

History and Symptoms

Throat Cancer usually begins with symptoms that seem harmless enough, like an enlarged lymph node on the outside of the neck, a sore throat or a hoarse sounding voice. However, in the case of throat cancer, these conditions may persist and become chronic. There may be a lump or a sore in the throat or neck that does not heal or go away. There may be difficult or painful swallowing. Speaking may become difficult. There may be a persistent earache. Other possible but less common symptoms include some numbness or paralysis of the face muscles.

Presenting symptoms include:

Other symptoms may include the following:

These symptoms may be caused by cancer or by other, less serious conditions. It is important to check with a doctor or dentist about any of these symptoms.

Differentiating head and neck cancer from other diseases

Head and neck cancer must be differentiated from congenital abnormalities, and malignant lesions.

Category Diseases Benign/

Malignant

Clinical manifestation Paraclinical findings Gold standard diagnosis Associated findings
Demography History Symptoms Signs Lab findings Histopathology Imaging
Pain Dysphagia Mass exam Others
Neoplasm Salivary gland neoplasm Pleomorphic adenoma[5][6] +
  • MRI: Homogenous on T1
  • Abundant myxochondroid stroma on T2
Warthin's tumor[7][8]
  • Male to female ratio: 4:1
  • More common in people aged 60-70 years old
+
Oncocytoma

[9]

  • Race: Caucasian patients predilection
  • Gender: No gender preference
  • Age: 50–70 years
± ±
  • CT:
    • Isodense expansive mass
    • Enhancement after intravenous contrast
    • Hypodense areas
  • MRI:
    • Isodensties on T1
    • Mass is hyperintense on T2
    • Enhancement on contrast
-
Monomorphic adenoma [10][11][12]
  • Age: 26-76 years
  • Rare in children
  • Gender: No predilection
± ±
  • Normal
-
Mucoepidermoid carcinoma

[13]

  • Age: Mean age of 59
  • Female predilection
± ±
  • Cystic and solid component with variable appearance on CT and MRI
  • Association with CMV
Category Diseases Benign Demography History Pain Dysphagia Mass exam Others Lab findings Histopathology Imaging Gold standard diagnosis Associated findings
Neoplasm Salivary gland neoplasm Adenoid cystic carcinoma [14]
  • Age: 40s-60s
  • Gender: Female predominance
± ±
Adenocarcinoma

[15]

  • Age: young age predilection
Salivary duct cancer[16][17][18]

(Highly aggressive)

  • Incidence: 1-3%
  • Gender: Male predilection
  • Mean age: 55-61 years old
  • Rapidly growing mass with jaw involvement
± ±
  • Painless
  • Hard
  • Non-compressible mass
Squamous cell carcinoma[19][20]
  • Incidence: rare
  • Age: Old age , 61-68 years
  • Male predilection
  • Present as painful growing mass on jaw
+
  • Tumor dimension can be delineated using both CT and MRI
Category Diseases Benign Demography History Pain Dysphagia Mass exam Others Lab findings Histopathology Imaging Gold standard diagnosis Associated findings
Neoplasm Hypopharyngeal cancer[21][22][23]
  • More common in males
  • Age: 55-65 years old
  • Incidence: < 1/100,000 in U.S.
  • More common in Japan, India, Iran
+
Parathyroid cancer[24][25][26]
  • Incidence: Rare
  • Mean age : 44-54 years old
  • Gender: Female predilection
+ +
Carotid body tumors[27][28][29][30]
  • Age: 26-55 years
  • Male predominance
+
Paraganglioma[31][32][33]
  • Age 50-70 years
  • More in females
Category Diseases Benign Demography History Pain Dysphagia Mass exam Others Lab findings Histopathology Imaging Gold standard diagnosis Associated findings
Neoplasm Schwannoma[34][35][36]
  • Rare tumor
  • Incidence: 1-10%
+ ±
  • Multiple
  • Slow growing nodules on the skin
  • May be normal
  • Encapsulated neural tissue growth
Lymphoma [37][38][39][40][41][42]
  • Age: Predilection for older age
  • Mean age: 55
±
  • On complete node analysis four patterns are described:
    • Nodular/follicular
    • Diffuse pattern
    • Transition from a nodular to a diffuse pattern in adjacent nodes
    • Transition from a lower to a higher grade of involvement within a single node
Liposarcoma [43][44][45][46]
  • Rare tumor
  • Age: Relatively in older age
  • Gender: No gender predilection
  • Mobile mass
  • Few symptoms until they grow enough to compress the surrounding structures
  • Symptoms of neural deficit, pain, tingling, or skin changes
±
  • Intact skin and normal color
  • Normal
Category Diseases Benign Demography History Pain Dysphagia Mass exam Others Lab findings Histopathology Imaging Gold standard diagnosis Associated findings
Neoplasm Lipoma [47][48][49]
  • One or multiple soft, painless skin nodules
  • May causes pain or compressive symptoms
±
  • Normal
  • Normal
  • Diagnoses is usually clinical
  • Tissue biopsy may show:
    • Bundle of well-demarcated lipocytes
    • Single nuclei aligned to the side
    • Intra-cytoplasimic fat granules
Glomus vagale, glomus jugulare tumors[50][51][52][53][54][55]
  • Rare tumor
  • Painless slowly enlarging mass in the neck
±
  • Normal
Metastatic head and neck cancer[56][57] ±
  • Vary depending on the underlying cancer
Category Diseases Benign Demography History Pain Dysphagia Mass exam Others Lab findings Histopathology Imaging Gold standard diagnosis Associated findings
Other Laryngeal cancer[58][59] Benign/Malignant
  • Older males
  • Younger patients with HPV infection or smoking history
± ±

human papillomavirus (HPV) infection

Arteriovenous fistula

[60][61]

  • Depends on the risk factors
  • Varies depending on the etiology
Thyroid nodule/ Goiter

[62][63][64][65]

  • Female predominance
  • Young age (benign causes)
  • Old age (malignant etiology)
± ±
  • Painless
  • Non-tender
  • Asymmetrical neck mass in front of neck
  • With smooth overlying skin
  • Nodular surface
  • Depending on the type:
  • Normal to low TSH levels in case of malignancy
  • High TSH levels in case of goiter
Category Diseases Benign Demography History Pain Dysphagia Mass exam Others Lab findings Histopathology Imaging Gold standard diagnosis Associated findings

Primary Prevention

  • Avoidance of recognised risk factors (as described above)is the single most effective form of prevention. Regular dental examinations may identify pre-cancerous lesions in the oral cavity.
  • It will be interesting to see what effect the widespread use of HPV vaccines has on the incidence of HPV-related H&N cancers.
  • People who have been treated for head and neck cancer have an increased chance of developing a new cancer, usually in the head and neck, esophagus, or lungs. The chance of a second primary cancer varies depending on the original diagnosis, but is higher for people who smoke and drink alcohol. Patients who do not smoke should never start. Those who smoke should do their best to quit. Studies have shown that continuing to smoke or drink (or both) increases the chance of a second primary cancer for up to 20 years after the original diagnosis.
  • Some research has shown that isotretinoin (13-cis-retinoic acid), a substance related to vitamin A, may reduce the risk of the tumor recurring (coming back) in patients who have been successfully treated for cancers of the oral cavity, oropharynx, and larynx. However, treatment with isotretinoin has not yet been shown to improve survival or to prevent future cancers.

References

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