What do we mean by head & neck cancers?
Cancer that develops in the mouth, nose, throat, salivary glands and other areas of head and neck.
More than 30 different areas, some include:
- mouth and lips
- vocal cords (larynx)
- throat (pharynx)
- salivary glands
- nose and sinuses
- area at the back of the nose and mouth (nasopharynx)
Oesophageal, thyroid, brain and eye cancer do not tend to be classified as a head and neck cancer.
How common is head & neck cancer?
Which gender more common in?
Age of presentation
- 8th most common in UK
- Men (4th most common) > women (13th most common)
- Most cases arise in those >50yrs (however, does occur in younger pts and when it does it is often due to HPV)
What type of cancer are over 90% of H&N cancers?
Squamous cell carcinomas
When thinking about H&N cancers, we can classify the cancers into 6 anatomical regions; each has a slightly different TNM classification & tumour pattern. State the 6 anatomical areas
- Sino-nasal (nose and sinuses)
- Nasopharynx (the back of the nose and very top of the throat)
- Oral (from lips, hard palate to anterior 2/3rds of the tongue)
- Oropharynx (posterior 1/3rd of the tongue, tonsils and soft palate)
- Hypopharynx (the area of the throat behind the vocal cords and above the oesophageal opening)
- Larynx (area of the voice box and airway inlet)
State some risk factors for H&N cancer
- Smoking
- Alcohol
- Betel nut chewing (mostly linked to oral cancer)
- Chewing tobacco
- Sunlight exposure
- Previous radiation to H&N
- Viruses e.g. HPV (especially HPV 16- linked mostly to oropharyngeal), EBV
- Occupational exposure e.g. wood dust (sinonasal), asbestos, formaldehyde
- Ethnicity: NPhx (check from lecture)
Many H&N cancers, particularly oral cancers, can develop from visible premalignant conditions; state some examples and describe their appearances
These conditions are heavily associated with smoking & alcohol consumption.
- Leukoplakia: white patch on oral mucous membranes that cannot be rubbed off
- Erythroplakia: red patch on oral mucous membranes
- Erythroleukoplakia: combination of the above
- Oral lichen planus: different presentations:
- White lace-like pattern that may also be swollen & red
- White & red patches
- Areas of ulceration
- Actinic cheilitis: most commonly affects lower lip: dry & cracked lips, thinned fragile skin, thickened scaly plaques & papules. Due to chronic sun exposure
Signs & symptoms of H&N cancer vary dependent on location of tumour; state some signs & symptoms of cancer in the oral cavity
*Most common symptoms are highlighted
- Mouth ulcers
- Unexplained, persistent lumps in mouth
- Pain, discomfort in mouth
- Unusual bleeding in mouth
- Numbness in mouth
- Loose teeth for no clear reason
*NOTE: erythroplakia (red patches) and leukoplakia (white patches) can be a sign of precancerous changes. Note if patch rubs off/away then more likely thrush
Signs & symptoms of H&N cancer vary dependent on location of tumour; state some signs & symptoms of cancer in the oropharynx, laryngopharynx/hypopharynx
*Most common symptoms are highlighted
- Persistent swelling or lump in neck (>3 week)
- Sore throat or tongue
- Earache
- Difficulty swallowing, moving mouth & jaw
- Bad breath
- Changes to voice
- Unequal looking tonsils
Signs & symptoms of H&N cancer vary dependent on location of tumour; state some signs & symptoms of cancer in the nasopharynx
*Most common symptoms are highlighted
- Persistent neck lump (>3 weeks)
- Nosebleeds
- Blocked or stuffy nose
- Hearing loss (unilateral)
- Tinnitus
- Numbness in lower part of face
- Double vision
- Headaches
- Difficulty swallowing
Signs & symptoms of H&N cancer vary dependent on location of tumour; state some signs & symptoms of cancer in the larynx
*Most common symptoms are highlighted
- Hoarse voice (> 3 weeks)
- Sore throat
- Difficulty swallowing
- Dysphagia
- SOB
- Sensation of lump in throat
- Halitosis (bad breath)
Signs & symptoms of H&N cancer vary dependent on location of tumour; state some signs & symptoms of cancer in the nose & sinuses
- Nosebleeds
- Unilateral persistent stuffiness/blocked nose
- Decreased sense of smell
- Blood stained mucus
- Post-nasal drip
- Persistent lump
- Eye problems (visual changes, swelling)
- Pain, numbness & paraesthesia in upper cheek
- Lump in neck
Signs & symptoms of H&N cancer vary dependent on location of tumour; state some signs & symptoms of cancer in the salivary glands
- Lump or swelling near jaw, mouth or neck (this could be gland or lymph nodes)
- Numbness in face
- Facial palsy/drooping one side of face
- Difficulty swallowing
- Difficulty opening mouth fully
Cancer is most common in which salivary gland?
Parotid
Discuss the 2WW referral criteria for suspected oral cancer (HINT: think about referral a dentist and to a doctor)
Consider 2WW referral for oral cancer in people with either:
- Unexplained ulceration in oral cavity lasting >3 weeks
- Or a persistent & unexplained lump in the neck
Consider an urgent (within 2 weeks) referral for assessment for possible oral cancer by a dentist who people with either:
- A lump on lip or in oral cavity
- Or a red or red & white patch in oral cavity consistent with erythroplakia or ertyrholeukoplakia
Discuss the 2WW referral for suspected laryngeal cancer
Consider 2WW referral for people aged >/=45yrs with either:
- Persistent, unexplained hoarseness
- Or an unexplained lump in the neck
Summary of NICE guidelines for H&N cancer 2WW referral
Image shows what PassMedicine says about 2WW referral for mouth lesions
What investigations will be done for suspected H&N cancer?
In order to visualise lesion:
- FNE (flexible nasal endoscopy): put camera inside nose and can visualise nose, nasopharynx & oropharynx; can be done in clinic
Main investigation required is biopsy; method will be dependent on location of suspected lesion, options include:
- Ultrasound guided FNA: for pts solely presenting lymphadenopathy
- Panendoscopy & biopsy EUA: put camera up nose & down throat whilst under GA. Can visualise lesion & take biopsy
- Send biopsy for P16 staining/immunohistochemistry: detects HPV, 3+ staining correlates to positive HPV PCR (of particular importance/usefulness in oral & oropharyngeal cancers)
Then will need to stage cancer:
- CT scan of neck & chest: estimate extension & invasion
- MRI neck scan: superior for assessing oral cavity & oropharyngeal lesions hence these pts will also have MRI
- PET scan
What staging is used for H&N cancers?
TNM
**Don’t need to know details
Explain why H&N cancers can spread easily/present at advanced stage
Why do patients with glottic tumours have a better prognosis?
- H&N cancers spread easily due to rich vascular supply and lymphatic drainage. Mostly results in:
- Local invasion
- Lymph node spread
- Other organs (primarily lung, but also bone, liver & brain)
- Pts with glottic tumours have better prognosis because they present earlier with hoarse voice and there is no lymphatic drainage from glottis hence this limits local metastatic spread
Discuss the mainstay of management for most H&N cancers (asking about generic principles of management- no region & stage specific management)
Management varies dependent on location, size, stage & grade aswell as pt factors. Involves MDT management. Mainstay of management for most H&N cancers:
- Surgical resection +/- adjuvant radiotherapy or chemotherapy
- Or primary radiotherapy +/- adjuvant chemotherapy
Discuss the management of:
- Small tumours of oral cavity
- Larger tumours of oral cavity
- Small tumours: wide local excision +/- neck dissection
- Larger tumours: surgical resection +/- flap reconstruction + neck dissection +/- adjuvant chemotherapy or radiotherapy
Discuss the management of:
- Small tumours of oropharynx (including tonsils)
- Larger tumours of oropharynx (including tonsils)
- Small tumours oropharynx: surgical transoral resection using laser or robot +/- neck dissection or radiotherapy
- Larger tumours: primary radiotherapy +/- adjuvant chemotherapy
Discuss the management of:
- Small tumours of larynx
- Larger tumours of larynx
- Recurrent tumours of larynx
- Small tumours (T1/T2): surgical transoral laser resection + neck dissection or radiotherapy +/- adjuvant chemotherapy
- Larger tumours (T4a): laryngectomy with adjuvant radiotherapy +/- chemotherapy
- Recurrent: salvage laryngectomy
Discuss the management of:
- Very small tumours of hypopharynx/laryngopharynx
- Other tumours of hypopharynx/laryngopharynx
- Very small tumours: laser resection
- Others: laryngopharyngectomy
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