Head And Neck Cancers

Question 1

Head and neck cancer is an umbrella term for what sub types?

Answer 1

Lip/ oral cavity cancers
Pharynx - nasopharynx, oropharynx, hypopharynx
Larynx - supraglottis, glottis, subglottis
Nasal cavity/ sinuses
Salivary glands - parotid, SMG, sublingual
Thyroid

Question 2

Over 90% derive from what type of epithelium?

Answer 2

Squamous cell epithelium

Hence they are often referred to as Head and Neck Squamous Cell Carcinomas (HNSCC)

Question 3

Are they more common in men or women?

Answer 3

At least twice as common in men

Question 4

What risk factors are there for HNSCCs?

Answer 4

Smoking
Alcohol
Betal nut chewing
Dental hygiene
Occupational wood dust exposure - sinonasal cancer
Viruses - HPV for oropharyngeal cancer, EBV nasopharyngeal cancer

Question 5

What type of HPV is linked to oropharyngeal cancer?

Answer 5

Type 16

Question 6

Many HNSCCs begin as a visible premalignant condition such as…

Answer 6

Leukoplakia - white patches 
Erythroplakia - red patches 
Erythroleukoplakia - mix or red and white patches
Oral lichen planus 
Actinic cheilitis

Question 7

A visible premalignant condition is typically seen in what cancers?

Answer 7

Oral cancers

Question 8

What is the lifetime risk of premalignant conditions transforming?

Answer 8

0-20%

Consequently, most suspected pre malignant conditions require further histological assessment - biopsy

Question 9

What thyroid specific risk factors are there for cancer?

Answer 9

Irradiation exposure
Family history
Inherited conditions

Young lumps or old lumps in thyroid glands more likely to be malignant

Question 10

How do lip/oral cavity cancers present?

Answer 10

Lump 
Pain - including referred pain e.g to ear 
Fixation of tongue
Dysphagia
Odonophagia 
Bleeding

Question 11

How to pharyngeal cancers present?

Answer 11

Odonophagia
Dysphagia
Pain including referred otalgia 
Lump 
Stertor (snoring noise due to airway obstruction) 
Weight loss

Question 12

Pharyngeal cancers often present late. True or false?

Answer 12

True 25% untreatable at presentation

Majority, specifically hypopharynx will have advanced stage at time of diagnosis, as they will often metastasise early due to extensive lymphatic network

Question 13

How do laryngeal cancers present?

Answer 13

Dysphonia e.g hoarse voice 
Stridor if advanced
Dysphagia
Persistent cough 
Referred otalgia 
Neck lump 
Weight loss
Cacexia

Question 14

Laryngeal cancers divided anatomically - supraglottis, glottis and subglottis. Where do most malignancies originate?

Answer 14

Glottis region

Question 15

Why do those with glottis tumours have better prognosis?

Answer 15

Present earlier with hoarse voice and there is no lymphatic drainage from glottis - limits any metastatic spread locally

Question 16

What investigations are done for suspected HNSCCs?

Answer 16

Flexible nasal endoscopy - examination under anaesthesia and biopsy of lesion
If presenting solely with lymphadenopathy - ultrasound guided FNA

Staging - CT scan neck and chest

PET CT for tumours of unknown origin

MRI is superior in assessing oral cavity and oropharyngeal lesions - so they will undergo MRI neck and CT chest

Question 17

Why is a CT chest included for staging?

Answer 17

To assess for any lung mets

Question 18

How are HNSCCs managed?

Answer 18

Varies depending on site, size, stage, grade, patient preference, comorbidities

Surgical resection +/- adjuvant radiotherapy or chemotherapy

OR primary RT +/- adjuvant chemotherapy

Question 19

What is the NICE cancer pathway referral criteria for laryngeal cancer (for an appointment within 2 weeks)?

Answer 19

In people over 45 with:
Persistent unexplained hoarseness
Unexplained neck lump

Question 20

What is the NICE cancer pathway referral criteria for oral cancer (for an appointment within 2 weeks)?

Answer 20

Unexplained ulceration in oral cavity lasting more than 3 weeks
Persistent unexplained neck lump
Lump on lip or in oral cavity
Red or red and white patch in oral cavity - erythroplakia or erythroleukoplakia

Question 21

What complications can occur following treatment?

Answer 21

Dysphagia - strictures
Pharyngocutaneous fistula
Injury to accessory, vagus, hypoglossal nerves
Mucositis or xerostomia - RT

Question 22

What is the most commonly used staging system in head and neck cancers?

Answer 22

TNM
Tumour size
Nodal mets
M distant mets

Question 23

What is the issue with doing an open biopsy of a neck mass (lymph node)?

Answer 23

Can lead to seeding of the tumour through the wound onto the skin - end up with a worse prognosis for the patient

Question 24

What is a FNA good and not so good at diagnosis?

Answer 24

Good at diagnosing squamous cell carcinoma

Not as good at diagnosing other causes of cervical lymphadenopathy e.g TB and lymphoma - often require an open biopsy