10 - Head and Neck Flashcards
Where are the different head and neck cancers?
USUALLY SQUAMOUS CELL
- Oral cavity (6th most common)
- Salivary glands
- Pharynx (oropharynx, hypopharynx and nasopharynx)
- Larynx (11th most common)
- Thyroid (20th most common)
What are some risk factors for head and neck cancers and where do they spread to first?
Spread to lymph nodes
- Smoking
- Chewing tobacco
- Chewing betel quid
- Alcohol
- HPV, particularly strain 16
- Epstein–Barr virus (EBV)
- UV
What are some red flags for head and neck cancer?
- 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
How is H+N cancer staged and managed in general terms?
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
Who is part of the MDT for head and neck cancer?
- ENT
- Plastics
- Maxillofacial surgeons
- Dentists
- Radiologists
- Oncologists
- SALT
- Dieticians
- Physio
- Palliative car expert
How may oral cancer present?
- Persistent ulceration
- A mass
- Abnormal bleeding
- Regional lymphadenopathy
What is the referral criteria for oral cancer on a 2 week wait and what is the investigation done under the 2 week wait?
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
What is the prognosis with oral cancer?
Usually presents late so 5 year survival <60%
How is oral cancer managed?
- Remove risk factors
- Surgical excision (usually Moh’s) +/- radiotherapy
- Reconstruction
- Lymph node dissection
- Cetuximab if late stage
How may laryngeal cancer present?
- Hoarseness
- Sore throat
- Dysphonia
- Referred otalgia
- Lymphadenopathy >3 weeks
- Dysphagia
What criteria needs to be fulfilled for a 2 week wait referral for laryngeal cancer?
Aged 45 years and over with:
- Persistent unexplained hoarseness or
- An unexplained lump in the neck.
What investigation is done on the 2 week wait for suspected laryngeal cancer?
Flexible Laryngoscopy
How is laryngeal cancer managed if glottic or supraglottic?
Systemic therapy with Cetuximab, Cisplatin and Fluorouracil
How is subglottic laryngeal cancer managed?
Systemic therapy with Cetuximab, Cisplatin and Fluorouracil
How are patients with treated laryngeal cancer followed up?
- 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
What is the prognosis with laryngeal cancer?
70% 5 year survival
Risk of recurrence massively increases if patient continues to smoke
What are the types of thyroid cancer (most to least common)?
How do each of the different types of thyroid cancer act?
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
What are key risk factors for thyroid cancer?
- Neck radiation
- Female
How may thyroid cancer present?
- Palpable nodule
- Diffuse thyroid swelling
- Dysphagia
- Hoarseness
- Stridor
- Lymphadenopathy
- Dyspnea
What criteria would warrant a 2 week wait referral for thyroid cancer?
- Unexplained thyroid lump
How are thyroid lumps investigated on the 2 week wait pathway?
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
What investigation should be done for thyroid cancer before surgery?
Evaluate vocal cord function with Fiberoptic Nasendoscopy (FNE) pre-operatively
What are the surgical options in thyroid cancer management?
- Hemithyroidectomy: low risk with no spread
- Total thyroidectomy: risk of hypoparathyroidism and more complications
- Lymph node dissection
What post op care is given after a thyroidectomy?
- 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
What are the complications with thyroid surgery and how would they present?
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
What are some adjuvant therapies given after a thyroidectomy to prevent recurrence?
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
What are the risks of giving supra-normal levels of levothyroxine for TSH suppression?
- Osteoporosis
- AF
- Cardiovascular disease
What are the side effects of radioactive iodine?
Nausea, vomiting, and dryness of the mouth
What protein is used to measure for disease recurrence after thyroid cancer surgery?
Thyroglobulin
Measured 6 weeks after surgery, difficult to tell if hemithyroidectomy as could be residual tissue producing it not cancerous cells
How is papillary and follicular thyroid cancer managed in general terms?
- 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
How is medullary thyroid cancer managed?
How is anaplastic thyroid cancer managed?
Palliative - surgery is to relieve airway obstruction
What is the prognosis with thyroid cancer?
- Papillary: 10 year survival >90%
- Follicular: Slightly worse prognosis
- Medullary: 5 year survival 80%
- Anaplastic: few months to live
What needs to be done before any radiotherapy?
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)
What is the difference between watchful waiting and active surveillance in prostate cancer?
