Head and Neck Cancers

Question 1

Define a head and neck cancers (areas)?

Answer 1

Any malignant tumour which develops in the: oral cavity, pharynx, paranasal sinuses, nasal cavity, larynx or salivary glands.

Many trusts also include malignant tumours of the skin of the head and neck and thyroid tumours.

Most common: Laryngeal
Hypopharyngeal
Least common: Oropharynx

Question 2

What are the risk factors for the development of head and neck tumours?

Answer 2

Age
Male gender

Squamous cell carcinomas: most common
Smoking and tobacco products (chewing leaves)
Alcohol

Cancers of the nose and sinus:
Certain chemicals and hardwood dusts.

Leukoplakia (white spots in the mouth) pre-malignant in a third of people.

Excessive sun exposure (skin cancers)

Question 3

Describe leukoplakia and erythroplakia and their significance?

Answer 3

Leukoplakia: White spots in the mouth.
Erythroplakia: Erythematous area on a mucous membrane.

The presence of either of these in the mouth classifies as a pre-malignant change.

Any white or red areas which do not disappear within 2 weeks should be evaluated by a specialist.

Question 4

Describe the common symptoms associated with cancers of the head and neck ?

Answer 4

Persistent pain in the throat.
Referred ear pain (CN V, VII, IX) oral cavity/oropharynx carcinomas.

Odynophagia.
Dysphagia.

Persistent hoarse voice/change in voice.
Lympathendopathy.

Bleeding in the mouth or throat.
Persistent ulceration, leukoplakia or erythroplakia.

Weight loss is rare, should only be associated with dysphagia otherwise seek alternative diagnosis.

Question 5

What investigations would you carry out on a patient suspected of having a head/neck cancer?

Answer 5

Bloods: U&E’s, FBC, LFT, Glucose, Albumin, TFT

Imaging:
CXR/CT chest
CT/MRI skull base to thoracic inlet

Fine Needle Aspiration for Cytology (FNAC)
May be US/CT guided

Question 6

Describe the staging system of head and neck cancers and outline the principles of treatment?

Answer 6

TNM system:
Tumour I-IV referring to size and local invasion
Nodes 0-3 referring to spread to and size of lymph nodes
Metasases: 0-1

Treatment plans for all patients must be discussed at an MDT. Treatment is divided into palliative or curative. Therapies usually involve a combination of surgery/radiotherapy/chemo.

Question 7

Describe the distribution of salivary gland tumours and the proportion which are malignant aka which salivarly glands are most likely to be affected?

Answer 7

80% of salivary tumour occur in the parotid gland, 80% of these are benign.

The rest occur in other salivary glands.
60% of submandibular tumours are benign.
30% of minor salivary gland tumours are benign.

Question 8

What is the most common benign salivary gland tumour and how is it treated?

Answer 8

Pleomorphic adenoma usually in the parotid.

Treated by surgical removal either superficial parotidectomy or if large a complete parotidectomy.

Question 9

What are the different malignant salivary gland tumours and there rough prognosis?

Answer 9

Adenoid cystic carcinoma. Most common and relatively good prognosis 15 year survival 10-26%.

Carcinoma ex pleomorphic adenoma. A malignant tumour which develops within a pleopmorphic adenoma, usually presents 10-15 years after the adenoma.

Adenocarcinoma. Highly malignant.

Metastatic ca:
Locally from malignant melanomas and SCC.
Distantly from lung, breast kidney and GI.

Note Lymphoma’s can often present as a rapidly enlarging mass in the neck, most commonly non hodgkins lymphoma.

Question 10

In a patient presenting with a neck swelling what questions are important to ask in a hx?

Answer 10

Onset. Time course.

Swelling: constant or intermittent. Uni/bilateral
Pain: SOCRATES, related to food (swelling and pain after food points more towards an obstruction aka sialectasis)

Foul taste in mouth (tonsilitis, mumps other infections)
Facial weakness. (CNVII involvement)
Change in voice. (Recurrent laryngeal involvement)
Dry eyes/mouth. (Sjogrens)
Trismus (inability to open mouth many causes ranging from inf to malignancy)
Displaced tonsil (quinsy aka peritonsilar abcess)

Question 11

What examinations would you do in a patient with a neck swelling?

Answer 11

Neck examination, if Ca likely think mets exam abdo and lungs.

Cranial nn.

Oral cavity + bimanual palpation.

Question 12

What non invasice investigations might you do in a patient presenting with a neck swelling?

Answer 12

Obviously dependent on differentials.

Routine bloods.
Virology (mumps)
SSA and SSB antigens (sjogrens)
X ray plain (sialectasis)
Doppler (aneurysm)
MRI

Question 13

What histological investigations might you do if you suspect malignancy?

Answer 13

FNAC

Biopsy gland if it is a minor salivary gland or the overlying skin is ulcerated.

Sublabial biopsy for non neoplastic disease.