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Y4 Cancer Care > 10 - Head and Neck > Flashcards

10 - Head and Neck Flashcards

1
Q

Where are the different head and neck cancers?

A

USUALLY SQUAMOUS CELL

  • Oral cavity (6th most common)
  • Salivary glands
  • Pharynx (oropharynx, hypopharynx and nasopharynx)
  • Larynx (11th most common)
  • Thyroid (20th most common)
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2
Q

What are some risk factors for head and neck cancers and where do they spread to first?

A

Spread to lymph nodes

  • Smoking
  • Chewing tobacco
  • Chewing betel quid
  • Alcohol
  • HPV, particularly strain 16
  • Epstein–Barr virus (EBV)
  • UV
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3
Q

What are some red flags for head and neck cancer?

A
  • Lump in the mouth or on the lip
  • Unexplained ulceration in the mouth lasting more than 3 weeks
  • Erythroplakia or erythroleukoplakia
  • Persistent neck lump
  • Unexplained hoarseness of voice
  • Unexplained thyroid lump
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4
Q

How is H+N cancer staged and managed in general terms?

A

TNM

Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck

Targets epidermal growth factor receptor

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5
Q

Who is part of the MDT for head and neck cancer?

A
  • ENT
  • Plastics
  • Maxillofacial surgeons
  • Dentists
  • Radiologists
  • Oncologists
  • SALT
  • Dieticians
  • Physio
  • Palliative car expert
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6
Q

How may oral cancer present?

A
  • Persistent ulceration
  • A mass
  • Abnormal bleeding
  • Regional lymphadenopathy
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7
Q

What is the referral criteria for oral cancer on a 2 week wait and what is the investigation done under the 2 week wait?

A

Biopsy

Suspected cancer pathway referral

  • Unexplained ulceration lasting for more than 3 weeks
  • A persistent and unexplained lump in the neck

Urgent referral for assessment for possible oral cancer by a dentist

  • A lump on the lip or in the oral cavity or
  • A red or red and white patch consistent with erythroplakia or erythroleukoplakia

Dentist can then 2 week wait them

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8
Q

What is the prognosis with oral cancer?

A

Usually presents late so 5 year survival <60%

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9
Q

How is oral cancer managed?

A
  • Remove risk factors
  • Surgical excision (usually Moh’s) +/- radiotherapy
  • Reconstruction
  • Lymph node dissection
  • Cetuximab if late stage
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10
Q

How may laryngeal cancer present?

A
  • Hoarseness
  • Sore throat
  • Dysphonia
  • Referred otalgia
  • Lymphadenopathy >3 weeks
  • Dysphagia
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11
Q

What criteria needs to be fulfilled for a 2 week wait referral for laryngeal cancer?

A

Aged 45 years and over with:

  • Persistent unexplained hoarseness or
  • An unexplained lump in the neck.
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12
Q

What investigation is done on the 2 week wait for suspected laryngeal cancer?

A

Flexible Laryngoscopy

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13
Q

How is laryngeal cancer managed if glottic or supraglottic?

A

Systemic therapy with Cetuximab, Cisplatin and Fluorouracil

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14
Q

How is subglottic laryngeal cancer managed?

A

Systemic therapy with Cetuximab, Cisplatin and Fluorouracil

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15
Q

How are patients with treated laryngeal cancer followed up?

A
  • Regular surveillance for cancer recurrence for 5 years after treatment (flexible fibre-optic laryngoscopy every 1 to 2 months for the first year after treatment, every 2 to 3 months for the second year, every 3 to 4 months for the third year, every 4 to 6 months for the fourth year, and every year thereafter)
  • Patients with suspicious lesions or neck masses undergo repeat CT imaging and biopsy
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16
Q

What is the prognosis with laryngeal cancer?

A

70% 5 year survival

Risk of recurrence massively increases if patient continues to smoke

17
Q

What are the types of thyroid cancer (most to least common)?

A
18
Q

How do each of the different types of thyroid cancer act?

A

Papillary cancer

  • Most common (70%)
  • Tends to present 30-40 years of age in females
  • Small tumours have an excellent prognosis

Follicular cancer

  • Second most common
  • More common in areas of low iodine and in women
  • Tends to present 30-60 years of age.
  • Is more likely to metastasise (to lung and bones) than locally invade

Medullary cancer

  • Relatively uncommon (5%)
  • Derived from calcitonin producing C-cells so can occasionally present with hypocalcaemia and diarrhoea secondary to raised calcitonin.
  • Associated with Multiple endocrine neoplasia (MEN Type 2A)
  • Often metastasis to lymph nodes
  • Prognosis worse than papillary and follicular carcinoma

Anaplastic cancer

  • The least common.
  • Present between 60-70 years old.
  • Extremely aggressive
  • Invasion of the trachea, recurrent laryngeal nerve by the time of presentation.
  • Extremely poor prognosis – median survival: 8 months

Thyroid Lymphoma

  • Accounts for 10% of thyroid cancers
  • Almost always Non-Hodgkins lymphoma
  • Mainly occurs between 50-80 years old.
  • Highly associated with Hashimoto’s thyroiditis
19
Q

What are key risk factors for thyroid cancer?

A
  • Neck radiation
  • Female
20
Q

How may thyroid cancer present?

A
  • Palpable nodule
  • Diffuse thyroid swelling
  • Dysphagia
  • Hoarseness
  • Stridor
  • Lymphadenopathy
  • Dyspnea
21
Q

What criteria would warrant a 2 week wait referral for thyroid cancer? b

A
  • Unexplained thyroid lump
22
Q

How are thyroid lumps investigated on the 2 week wait pathway?

A

Triple Assessment

1. History, examination and thyroid function tests

Exam nodule and Lymph nodes

2. Ultrasound scan

A score U 1-5 is given based on the radiographical appearance of the nodule

Any lymphadenopathy, retrosternal extension or tracheal compression should be commented upon.

FNAC should be carried out on all U 3 – 5 lesions

3. Fine needle aspiration cytology

Sample thyroid lump and any suspicious lymph nodes

23
Q

What investigation should be done for thyroid cancer before surgery?

A

Evaluate vocal cord function with Fiberoptic Nasendoscopy (FNE) pre-operatively

24
Q

What are the surgical options in thyroid cancer management?

A
  • Hemithyroidectomy: low risk with no spread
  • Total thyroidectomy: risk of hypoparathyroidism and more complications
  • Lymph node dissection
25
Q

What post op care is given after a thyroidectomy?

A
  • Serum calcium (+/- PTH) monitored post-operatively. Normally that evening and the following morning at a minimum
  • Fiberoptic Nasendoscopy (FNE) to confirm normal function of vocal cords and no recurrent laryngeal nerve issue
26
Q

What are the complications with thyroid surgery and how would they present?

A

Recurrent Laryngeal Nerve Palsy

  • Change in voice
  • Stridor if bilateral

Haematoma

  • Stridor
  • Open sutures and return to theatre immediately

Hypoparathyroidism

  • Tingling around mouth and fingers
  • Around 30% of patients will need calcium (+/- alfacalcidol) supplementation after a total thyroidectomy
  • Usually transient
27
Q

What are some adjuvant therapies given after a thyroidectomy to prevent recurrence?

A

Radioiodine remnant ablation

131Iodine

External beam radiotherapy

Patients with high-risk features (high risk of recurrence, local spread, residual/recurrent tumour).

May also be used in the palliative setting, particularly if bone/spinal mets

Levothyroxine

For TSH suppression

28
Q

What are the risks of giving supra-normal levels of levothyroxine for TSH suppression?

A
  • Osteoporosis
  • AF
  • Cardiovascular disease
29
Q

What are the side effects of radioactive iodine?

A

Nausea, vomiting, and dryness of the mouth

30
Q

What protein is used to measure for disease recurrence after thyroid cancer surgery?

A

Thyroglobulin

Measured 6 weeks after surgery, difficult to tell if hemithyroidectomy as could be residual tissue producing it not cancerous cells

31
Q

How is papillary and follicular thyroid cancer managed in general terms?

A
  • Total thyroidectomy
  • Followed by radioiodine (I-131) to kill residual cells
  • Levothyroxine extra replacement for TSH suppression
  • Yearly thyroglobulin levels to detect early recurrent disease
32
Q

How is medullary thyroid cancer managed?

A
33
Q

How is anaplastic thyroid cancer managed?

A

Palliative - surgery is to relieve airway obstruction

34
Q

What is the prognosis with thyroid cancer?

A
  • Papillary: 10 year survival >90%
  • Follicular: Slightly worse prognosis
  • Medullary: 5 year survival 80%
  • Anaplastic: few months to live
35
Q

What needs to be done before any radiotherapy?

A

Dietician: oral mucositis. This will cause pain and soreness leading to difficulty swallowing and reduced oral intake.

Dental review: any decayed teeth should be removed before starting radiotherapy. This is because there is a risk of osteoradionecrosis, if teeth are extracted AFTER a course of radiotherapy

Smokers: increased toxicity with radiotherapy and response rates are not as good (due to hypoxia)

36
Q

What is the difference between watchful waiting and active surveillance in prostate cancer?

A

Y4 Cancer Care (19 decks)

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