5- Head and neck cancers Flashcards
epidiemology of H and N cancer
- 12,000 cases per year
o 4th most common in men
o 13th in women
key types of H and N cancer
o Oral cancer
o Nasal cancer
o Laryngeal cancer
o Thyroid cancer
pathophysiology of most H and N cancer
- Begin in the mucosal surfaces lining the cavities of the head and neck -> mostly squamous cell carcinoma
- Also of the salivary glands
Huge psychological impact of advanced H+N tumours
- Breathing
- Eating
- Communication
- Carotid
P16- tumour suppressor in H&N cancer
p16 is a tumor suppressor gene, over expression of which is considered as a surrogate marker of oncogenic human papillomavirus (HPV) infection. Moreover, p16 over expression correlates with good prognosis in head and neck squamous cell carcinoma (HNSCC).
Metastasis of H+N cancer
- Local invasion
- Lymph nodes
- Lungs
- Also bone, liver, brain
Risk factors of H+N cancer
- Smoking
- Alcohol
- Betel nut chewing
- HPV- oropharynx
- EBV- nasopharynx
- Wood dust
- Asbestos
- Ethnicity
presentation of H+N cancer
- Depends on location
- Often lymphadenopathy first noticed by patient
referral for H+N cancer
Referral
2- week wait referral if persistent and unexplained
- Lumps in the
o Neck
o Lip
o Oral cavity
- Ulceration in the oral cavity lasting more than 3 weeks
- Hoarseness
Investigation for H+N cancer
- US and final needle aspiration
- CT/MRI scan
- Panendoscopy (upper airway camera) and biopsy EUA
- PET scan
- P16 – blood test for tumour suppressor gene
general management of H+N cancer
red flag symptoms
staging of H+N cancers
Oral cancer
Background
- Lip/tongue/ oral cavity
- Premalignant conditions- white plaques on tongue
o Leucoplakia
o Erythroplakia - SCC
presentation of oral cancer
Presentation
- Lump
- Pain (but typically painless)
- Fixation of tongue
- Problems swallowing (dysphagia)
- Pain on swallowing (odynophagia)
investigations of oral cancer
Investigations
- Biopsy
- May need imaging with CT +/- MRI (including chest)- not needed for superficial lip lesion
- May need PET
Management of oral cancer
- Early tumour T1/T2 trans oral resection (laser or robotic + neck dissection)
- Large tumour- surgical resection +- flap reconstruction + neck dissection +- radio and chemo
laryngeal cancer background
Mainly SCC
Types
- Supraglottic
- Glottis (better prognosis due to becoming hoarse earlier)
- Subglottic
Presentation of laryngeal cancer
- Dysphonia (hoarse) - problems speaking
- Dysphagia
- Referred otalgia
- Globus- abnormal sensation of lump in throat
- Neck lump
- Weight loss
- Cachexia
- Stridor if advanced
Presentation of laryngeal cancer
- Dysphonia (hoarse) - problems speaking
- Dysphagia
- Referred otalgia
- Glovbus- abnormal sensation of lump in throat
- Neck lump
- Weight loss
- Cachexia
- Stridor if advanced
investigations for laryngeal cancer
Investigations
- Imaging with CT +/- MRI
- May need PET
- Biopsy during flexible nasal endoscopy (FNE)
- Fine needle aspiration of cervical lymphaendompathy
prognosis of laryngeal cancer
Prognosis
- Poor
- Often have long term voice issues and/or swallowing problems
management of laryngeal cancer
- Small tumours(T1/T2)may have laser resection or Radiotherapy (RT)
- Medium sized tumours do well with RT and chemo
-
Larger tumours (T4a) that do not respond to RT mat need extensive surgery (laryngectomy- remove voicebox and disconnected oral cavity from the airway)
o May need an electrical larynx
o Recurrent cancer: Salvage Laryngectomy
pharynx cancer background
- Location
o Oropharynx
o Nasopharynx
o Hypopharynx (majority) - Usually SCC
- Frequently at advanced stage and metastasise early
Presentation of pharynx cancer
often presents late – 25% untreatable at presentation
- Lump (mainly nodal mets or unknown primary)
- Pain- glossopharyngeal nerve (Referred otalgia )
- Dysphagia
- Pain on swallowing- odynophagia
- Weight loss
- Stertor (snoring noise)
- Trotters syndrome (nasopharyngeal malignancy)
1) Unilateral conductive hearing loss
2) Trigeminal neuralgia
3) Defective mobility of the soft palate
investigations for pharynx cancer
Investigation
- Imaging with CT +/- MRI
- May need PET
- Biopsy
management of pharynx cancer
- Small tumours undergo surgical resection using laser or transoral robotic surgery +- neck dissection or primary radiotherapy or both
- Large tumours undergo solely primary radiotherapy +/- adjuvant chemo
- Larger tumours that do not respond to RT may need extensive surgery (mandibular split or other type of pharngectomy or robotic procedure)
patients who have extensive surgery due to pharynx cancer will often need
need feeding assistance with gastrostomy tubes
types of thyroid cancer
Papillary adneocaricnoma (80%)
Follicular adenocarcinoma (10%)
Medullary carcinoma
Lymphoma
Anaplastic carcinoma
Papillary adenocarcinoma (80%)
- 40-50 yo females
- Multiple lesions rarely encapsulated
- Histologically cells are a mixture between papillary and colloid-filled follicles, with papillary projections and pale empty nuclei
- Spread via lymphatics
Follicular adenocarcinoma (10%)
- 40-60 females
- Focal encapsulated lesion with microscopic capsular invasion
- Haematogenous spread to bones and lungs
Medullary carcinoma
- Arise in parafollicular cells
- Produce raised calcitonin levels
- Associated with MEN 2 syndrome
- Spread via lymphatic and medullary routes
- Nodal disease associated with very poor prognosis
Anaplastic carcinoma
- Rare tumours
- Elderly
- Very aggressive
- Grow rapidly with earl local invasion
- Prognosis is poor
Lymphoma
Very rare
>60 yo
Grow rapidly
B-cell symptoms
Risk factors (specific to thyroid)
- Irradiation exposure (including radioactive iodine and radiation leaks)
- Family history e.g. FAP, MEN2
- Hashimoto’s disease
- Lumps in those <20 or >70 more likely to be malignant
presentation of thyroid cancer
Presentation
- Tend to present with a lump (in the thyroid or neck nodal metastasis)
- moves on swallow
- Rarely have problems with the thyroid status
Compressive symptoms
- Problems swallowing or feeling like being strangled
- Voice can change
Red flags
- Rapid growth
- Pain
- Cough, hoarse voice, stridor
- Multiple enlarged cervical lymph nodes
- Tethering of lump
examination for thryoid cancer
Swallow and stick out tongue
- Any lump related to thyroid will move on swallowing
- If the lump moves when tongue being stuck out- thyroglossal cysts
Investigations for thyroid cancer
Bloods
- TFTs
- Serum calcitonin may be useful for diagnosis and monitoring in medullary carcinoma
US imaging
- Microcalcification
- Hypoechogenicity
- Irregular margin
FNA if suspicious lump via cytology
Management of thyroid cancer
- Hemi-thyroidectomy or total thyroidectomy depending on type of carcinoma
- Neck dissection for N+ disease (locally advanced)
- Radioactive iodine
o Iodine is only used by thyroid gland- very useful target - Radiotherapy/ chemotherapy
Complications of thryoid surgery
-
Haematoma forming under the skin which can cause airway obstruction- emergency
–> Wound must be re-opened and drained -
Hypocalcaemia
–>If parathyroid gland removed - Vocal cord paralysis due to damage to the recurrent laryngeal nerve
prognosis of thyroid cancer
Prognosis
- For papillary cancer, prognosis is quite good with 10 year survival of 90% (this drops considerably if the tumour has spread beyond the gland)
- Follicular cancer has a high 10 year survival at around 85% (haematogenous spread is a marker of poorer prognosis)
- Medullary cancer also has a good prognosis, with 10 year survival dropping only below 90% when nodal or metastatic spread is seen.
- For anaplastic cancer, there is a very poor prognosis with a 1 year survival of 10-20%
neck lump differentials
