Head & Neck Cancer Flashcards
Common clinical features of head and neck cancers?
Dysphagia
Odynophagia
Dysphonia
ALARM symptoms (tiredness, unexplained weight loss, loss of appetite)
Lymphadenopathy
Airway compromise (stridor)
Bad breath (halitosis)
Focal neurology (VII cranial nerve palsy)
What is the most common malignancy of the endocrine system?
Thyroid cancer
What are the types of thyroid cancer?
(most common)
1. Papillary
2. Follicular
3. Medullary (5%)
4. Anaplastic
5. Thyroid Lymphoma
(least common)
What is the most common type of thyroid cancer?
Papillary
Around what age does papillary thyroid cancer tend to present?
30-40 years age
Spread of papillary thyroid cancer?
Locally compressing the trachea
Metastasises to bone and lung
Predominate lymph node metastasis
Haematogenous mets rare
Prognosis of papillary thyroid cancer?
Small tumours have an excellent prognosis
Second most common type of thyroid cancer?
Follicular cancer
In what areas and patients is follicular thyroid cancer more prevalent?
More common in areas of low iodine and in women
Around what ages does follicular thryoid cancer tend to present?
30-60 years
Spread of follicular thyroid cancer?
Is more likely to metastasise (to lung and bones) than locally invade
Vascular invasion predominates
Is medullary thyroid cancer common? What condition is it associated with?
Relatively uncommon form of thyroid cancer (5%)
Associated with Multiple endocrine neoplasia (MEN) syndrome type 2A and B although 75% are sporadic.
Prognosis of medullary thyroid cancer compared to more common subtypes?
Prognosis worse than papillary and follicular carcinoma
Nodal disease is associated with a very poor prognosis.
How can disease activity be monitored in medullary thyroid cancer and why?
Derived from calcitonin producing C-cells - disease can be monitored with calcitonin levels
From which cells is medullary thyroid cancer derived from?
Derived from calcitonin producing C-cells
C cells derived from neural crest and not thyroid tissue
Which type of thyroid cancer can occasionally present with hypocalcaemia and diarrhoea and why?
Medullary - Derived from calcitonin producing C-cells so can occasionally present with hypocalcaemia and diarrhoea secondary to raised calcitonin.
Spread of medullary thyroid cancer?
Often metastasis to lymph nodes
Both lymphatic and haematogenous metastasis are recognised, nodal disease is associated with a very poor prognosis.
What is the least common form of thyroid cancer?
Anaplastic
When do anaplastic thyroid cancers tend to present?
Ages 60-70 years
Spread of anaplastic thyroid cancer?
There is often invasion of the trachea, recurrent laryngeal nerve or other local structures by the time of presentation.
Which type of thyroid cancer might present with a particularly rapidly growing mass?
Anaplastic - Extremely aggressive, patients present with rapidly growing masses.
Prognosis of anaplastic thyroid cancer?
Extremely poor prognosis – median survival: 8 months
Extremely aggressive, patients present with rapidly growing masses.
There is often invasion of the trachea, recurrent laryngeal nerve or other local structures by the time of presentation.
Thyroid lymphoma - Hodgkins or Non-Hodgkins?
Almost always Non-Hodgkins lymphoma
At what ages does thyroid lymphoma typically present?
50-80 years
What autoimmune condition is thyroid lymphoma highly associated with?
Highly associated with Hashimoto’s thyroiditis
Differentials for a nodular goitre?
Toxic solitary adenoma
Non-functional thyroid adenoma
Multinodular goitre
Thyroid cyst
Cancer
How are papillary and follicular thyroid cancers managed?
total thyroidectomy
followed by radioiodine (I-131) to kill residual cells
How are papillary and follicular thyroid cancers monitored following treatment?
Yearly thyroglobulin levels to detect early recurrent disease
Histological characteristics of papillary thyroid carcinoma?
Usually contain a mixture of papillary and colloidal filled follicles
Histologically tumour has papillary projections and pale empty nuclei
They are rarely encapsulated
How does follicular adenoma present?
Solitary thyroid nodule/focal encapsulates lesions
R/O malignancy in a ?follicular adenoma - ie. solitary thyroid nodule?
Malignancy can only be excluded on formal histological assessment
Follicular thyroid carcinoma - macroscopic and microscopic features?
May appear macroscopically encapsulated, microscopically capsular invasion is seen.
Without this finding the lesion is a follicular adenoma.
What finding differentiates between thyroid follicular carcinoma and follicular adenocarcinoma
Microscopically, capsular invasion seen
How is anaplastic thyroid carcinoma managed?
Resection where possible
Palliation may be achieved through:
isthmusectomy and
radiotherapy.
Chemotherapy is ineffective.
Which type of thyroid cancer has the best prognosis?
Papillary
What type of thyroid cancer is associated most with pressure symptoms and poor response to treatment?
Anaplastic
What types of thyroid cancer are seen here?
- Papillary
- cells a mixture of papillary and colloid-filled follicles
with papillary projections
pale empty nuclei - Follicular
microscopic capsular invasion - Medulary
- Anaplastic
Risk factors for thyroid cancer?
Female gender
Family history
- Also includes relevant cancer syndromes (e.g. medullary subtype associated with Multiple Endocrine Neoplasia (MEN) Syndrome type IIa and IIb)
Radiation exposure in childhood
Full body radiotherapy for bone marrow transplant
Hashimoto’s disease (Predisposes to lymphoma subtype)
The red flag signs to be aware of with any neck lump that may suggest a malignancy are what?
Rapid growth
Pain
Cough, hoarse voice, or stridor
Multiple enlarged cervical lymph nodes
Tethering of the lump to surrounding structures
Thyroid cancers may present as a palpable lump, multiple lumps, or be found incidentally on imaging of the neck.
The red flag signs to be aware of with any neck lump that may suggest a malignancy are:
- Rapid growth
- Pain
- Cough, hoarse voice, or stridor
- Multiple enlarged cervical lymph nodes
- Tethering of the lump to surrounding structures
Thyroid cancer differentials
Benign thyroid adenoma or thyroid cyst
Toxic multi-nodular goitre
- Toxic refers to excessive productive of thyroid hormone which results in the clinical features of hyperthyroidism
Non-toxic multi-nodular goitre
Thyroglossal duct cyst* (not in the thyroid itself)
- Will move superiorly as the patient sticks out their tongue
When a ?thyroid cancer presents, and the mass is seen to move superiorly as the patient sticks out their tongue, what must be considered in investigating/managing the lump?
Thyroglossal cysts, prior to any suggested removal, should be fully investigated as the as the cyst may be the only functioning thyroid tissue that the patient has therefore would not warrant removal
What is evidence of a toxic thyroid nodule, and what are the implications of this?
low TSH
raised T3 or T4
Radio-nucleotide imagain showing a ‘‘hot’’ nodule
No further investigation for malignancy is required - overative nodules are very rarely malignant
What features on an ultrasound thyroid scan are suspicious of malignancy?
Microcalcifications
Hypoechongenicity (dark regions, decreased response)
Irregular margins
Investigating thyroid cancer?
TFTs (if evidence toxic nodule - no further investigation req.)
Ultrasound thyroid scan: assess nodule + look for cervical lymphadenopathy
FNA cytology if U3-U5 lesion
Diagnostic hemithyroidectomy if Thy 3 or Thy 4 on FNAC
What determines whether or not a thyroid nodule requires FNAC
US of thyroid
A score will be allocated (U1-U5). U1-U2 lesions have low risk of malignancy and will not require fine needle aspiration cytology (FNAC), U3-U5 lesions should undergo FNAC.
What is FNAC and how is it used in ?thyroid cancer
If U3-U5 on US, lesions will undergo fine needle aspiration cytology
Involves passing a neddle into the thryoid nodule and aspirating cells out of it
These cells will be reviewed and the relevant score allocated (Thy1-Thy5)
Thy 1- requires further sample
Thy 2 - non-malignant, no further action
Thy 3 - folicular lesion, requires diagnostic hemithyroidectomy
Thy 4 - suspicious, requires diagnostic hemithyroidectomy
Thy 5 - malignant and requires work up for appropriate treatment
Score allocation of ?thyroid cancer following FNAC
Thy1 is inconclusive and requires a further sample
Thy2 is non-malignant
Thy3 is follicular lesion and requires diagnostic hemithyroidectomy for histology to determine between follicular adenoma (benign) or carcinoma
Thy4 is suspicious and requires diagnostic hemithyroidectomy
Thy5 is malignant and requires work up for appropriate treatment
General management of thyroid cancer?
Thyroid cancer should be managed by a multi-disciplinary team, including endocrinologists, histopathologists, radiologists, oncologists, and ENT surgeons, alongside of specialist nurses and speech and language therapists.
The management varies depending on the type of cancer as well as the stage.
Management options include surgical, chemotherapy, radiotherapy, and radio-iodine therapy.
Surgical: hemi or total thyroidectomy - neck dissection to remove groups of lymph nodes from surrounding region
Non surgical: radioiodine therapy, external beam raidotherapy
What are the potential surgical options for managing thyroid cancer?
Hemi-thyroidectomy – This involves removing half of the thyroid that contains the lesion, however is only suitable for certain tumours (e.g. small low grade non-metastatic malignancy)
Total thyroidectomy – Most malignant disease will require a total thyroidectomy, which involves removing the whole thyroid (including the isthmus); patients will always need to take thyroid hormone replacement following this surgery
Locally advanced disease may also require neck dissection, to remove groups of lymph nodes from the surrounding region, both to aid diagnosis and attempt to reduce disease spread.
What are the potential non surgical complications of thyroid cancer?
Radioiodine therapy involves administration of a radioactive iodine solution, which is taken up preferentially by residual thyroid tissue, acting a focal radiation targeting the malignancy (used for papillary or follicular carcinomas). Only effective after total thyroidectomy.
External beam radiotherapy can be used as primary or adjunct therapy (curative or palliative).
Chemotherapy can be used as primary or adjunct therapy (curative or palliative) - classically lymphomas usually responding well to chemotherapy, and symptoms can improve within a few doses. Anaplastic tumours do not respond well to chemotherapy
Use of chemotherapy in thyroid cancer?
can be used as primary or adjunct therapy (curative or palliative)
classically lymphomas respond well
anaplastic carcinoma does not respond to chemotherapy
Follicular cancer has a high 10 year survival at around 85%, but what is a marker of poor prognosis?
Haematogenous spread
Under what circumstances radioiodine therapy useful for manage thyroid cancer?
Papillary or follicular carcinomas
Only effective after total thyroidectomy
Complications of thyroid surgery?
Haematoma formation beneath the skin, potentially causing airway obstruction (must be opened and drained on ward and return to theatre to stop bleeding)
Damage or removal of parathyroid gland - hypocalcaemia
Unilateral RLN damage - vocal cord paralysis - hoarse voice
Bilateral RLN damage - vocal cord paralysis - life threatening stridor
What must patients be monitored for clinical features of + when are bloods taken following a complete thyroidectomy?
Clinical features of hypocalcaemia, such as paraesthesia or tetany.
PTH and serum calcium levels must be checked the next day (however levels can become significantly low within hours post-operatively)
Because,
Hypocalcaemia may occur if there is damage to or removal of the parathyroid glands.
Clinical features of hypocalcemia?
Paraesthesia - usually of fingers, toes, cicumoral regions, cause be increase neuromuscular irritability
Tetany (involuntary contraction of muscles leading to painful cramps, spasms and neurological reflexes)
Chvostek’s sign - twitching of circumoral muscles in response to gentle tapping of the facial nerve just anterior to the ear
Trousseau’s sign - carpal spasm induced by inflation of a blood pressure cuff to 20 mmHg above the patient’s systolic blood pressure for 3 min
Prolonged QT interval
Bronchospasam
`What nerve is at risk during thyroid surgery and what are the implications of this?
The recurrent laryngeal nerves run close to the thyroid gland, hence care during surgery must to taken to prevent damage causing vocal cord paralysis. Unilateral palsy will result in a hoarse voice however a bilateral paralysis can result in a life-threatening stridor and tracheostomy may be warranted.
Why might thyroid surgery cause an airway emergency?
Bleeding immediately after the operation can result in a haematoma forming beneath the skin. Large haematomas can cause airway obstruction, which is an emergency. In this situation the surgical wound must be re-opened (on the ward!) to allow drainage of the haematoma and the patient will need to go back to theatre to stop the bleeding
The recurrent laryngeal nerves run close to the thyroid gland, hence care during surgery must to taken to prevent damage causing vocal cord paralysis. Unilateral palsy will result in a hoarse voice however a bilateral paralysis can result in a life-threatening stridor and tracheostomy may be warranted.
What problem can bleeding immediately following thyroid surgery cause?
Bleeding immediately after the operation can result in a haematoma forming beneath the skin. Large haematomas can cause airway obstruction, which is an emergency. In this situation the surgical wound must be re-opened (on the ward!) to allow drainage of the haematoma and the patient will need to go back to theatre to stop the bleeding
Medullary thyroid cancer has a good prognosis, with 10 year survival dropping only below 90% when?
When nodal or metastatic spread is seen.
Which thyroid cancer has the poorest prognosis?
For anaplastic cancer, there is a very poor prognosis with a 1 year survival of 10-20%
For papillary thyroid cancer- prognosis is good with a 10 year survival that drops below 90% only when what happens?
The tumour has spread beyond the gland
What are the are three descriptions to note the location of a neck lump?
Anterior triangle
Posterior triangle
(These two triangles are on either side of the sternocleidomastoid muscle)
Midline (vertically along the centre of the neck)
What are the borders of the anterior triangle
Superior: (inferior border) mandible
Medial: (saggital line down the) midline of neck
Lateral: (anterior border of) the sternocleidomastoid
What are the borders of the posterior triangle?
Anterior: (posterior border) of the sternocleidomastoid
Posterior: (anterior border) trapezius muscle.
Inferior: (middle 1/3 of) the clavicle
Neck lumps: DDx
Normal structures (e.g., bony prominence - hyoid bone, mastoid process, transverse processes of C1)
Skin abscess
Lymphadenopathy (enlarged lymph nodes)
Tumour (e.g., squamous cell carcinoma or sarcoma)
Lipoma
Goitre (swollen thyroid gland) or thyroid nodules
Salivary gland stones or infection
Carotid body tumour
Haematoma (a collection of blood after trauma)
Thyroglossal cysts
Branchial cysts
Neck lumps - additional DDx to consider in children
Cystic hygromas
Dermoid cysts
Haemangiomas
Venous malformation
What does history aim to gain when considering P/C: neck lump
General information about the symptoms (e.g., when the lump first appeared and how quickly it has grown)
Features that suggest or exclude a particular diagnosis (e.g., night sweats indicating lymphoma)
Risk factors for that condition (e.g., family history, age and smoking status)
General fitness for further investigations and treatment (e.g., co-morbidities and medications such as anticoagulants)
When examining a neck lump, what things should you establish?
Location (anterior triangle, posterior triangle or midline)
Size
Shape (oval, round or irregular)
Consistency (hard, soft or rubbery)
Mobile or tethered to the skin or underlying
tissues
Skin changes (erythema, tethering or ulceration)
Warmth (e.g., infection)
Tenderness (e.g., infection)
Pulsatile (e.g., carotid body tumours)
Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
Transilluminates with light (e.g., cystic hygroma – usually in young children)
When considering DDx for a neck lump, what signs might indicate underlying cause on general examination of the patient?
Ear, nose and throat infections (e.g., reactive lymph nodes)
Weight loss (e.g., malignancy or hyperthyroidism)
Skin pallor and bruising (e.g., leukaemia)
Focal chest sounds (e.g., lung cancer)
Clubbing (e.g., lung cancer)
Hepatosplenomegaly (e.g., leukaemia)
Neck Lump Red-Flag Referral Criteria
2ww referral for:
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
When do NICE recommend considering an urgent USS in patients presenting with a neck lump, and within what time frame?
They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size.
Within 2 weeks in patients 25 and older and
Within 48 hours in patients under 25.
They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
Blood tests may be helpful depending on the suspected cause of the neck lumps.
Not everyone with a neck lump will require blood tests.
The choice of test will depend on the suspected cause, ie?
FBC and blood film for leukaemia and infection
HIV test
Monospot test or EBV antibodies for infectious mononucleosis
Thyroid function tests for goitre or thyroid nodules
Antinuclear antibodies for systemic lupus erythematosus
Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
P/C neck lump: potential imaging?
Ultrasound is often the first-line investigation for neck lumps
CT or MRI scans
Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)
In a neck lump, biopsy may be required to gain a tissue sample (histology) to establish the exact cause.
What methods might be used to obtain a biopsy?
Fine needle aspiration cytology – aspirating cells from the lump using a needle
Core biopsy – taking a sample of tissue with a thicker needle
Incision biopsy – cutting out a tissue sample with a scalpel
Removal of the lump – the entire lump can be removed and examined
Lymphadenopathy of which of the cervical lymph nodes are most concerning for malignancy?
Supraclavicular - . They may be caused by malignancy in the chest or abdomen and require further investigation.
Lymphadenopathy - features suggesting malignancy?
Unexplained (e.g., not associated with an infection)
Persistently enlarged (particularly over 3cm in diameter)
Abnormal shape (normally oval shaped where the length is more than double the width)
Hard or “rubbery”
Non-tender
Tethered or fixed to the skin or underlying tissues
Associated symptoms, such as night sweats, weight loss, fatigue or fevers
What is lymphadenopathy and what are the general causes?
Lymphadenopathy refers to enlarged lymph nodes. There are a long list of causes of enlarged lymph nodes, which can be generally grouped into:
Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis)
Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis)
Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis)
Malignancy (e.g., lymphoma, leukaemia or metastasis)
A goitre refers to generalised swelling of the thyroid gland. A goitre can be caused by what?
Graves disease (hyperthyroidism)
Toxic multinodular goitre (hyperthyroidism)
Hashimoto’s thyroiditis (hypothyroidism)
Iodine deficiency
Lithium
Individual lumps can occur in the thyroid due to what?
Benign hyperplastic nodules
Thyroid cysts
Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
Thyroid cancer (papillary or follicular)
Parathyroid tumour
What are the three salivary gland locations?
Parotid glands
Submandibular glands
Sublingual glands
What are the three main reasons for enlargement of the salivary glands?
Stones blocking the drainage of the glands through the ducts (sialolithiasis)
Infection
Tumours (benign or malignant)
What is the carotid body, and what cells does it contain?
The carotid body is a structure located just above the carotid bifurcation (C3–5 vertebra, where the common carotid splits into the internal and external carotids).
It contains glomus cells, which are chemoreceptors that detect the blood’s oxygen, carbon dioxide, and pH.
Groups of these glomus cells are called paraganglia.
How does carotid body tumours present?
They present with a slow-growing lump that is:
In the upper anterior triangle of the neck (near the angle of the mandible)
Painless
Pulsatile
Associated with a bruit on auscultation
Mobile side-to-side but not up and down
Why do carotid body tumours occur and what problems can they cause?
Carotid body tumours are formed by excessive growth of the glomus cells.
They are also called paragangliomas.
Most are benign
Carotid body tumours may compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves.
Pressure on the sympathetic nerves may result in Horner syndrome, with a triad of:
Ptosis
Miosis
Anhidrosis (loss of sweating)
What is seen on imaging of a carotid body tumour?
A characteristic finding on imaging investigations is splaying (separating) of the internal and external carotid arteries (lyre sign).
How are carotid body tumours managed?
Surgical removal
What are lipomas - how do they present and how are they managed
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue.
On examination, lipomas are typically:
Soft
Painless
Mobile
Do not cause skin changes
They are typically treated conservatively with reassurance (after excluding other pathology). Alternatively, they can be surgically removed.
Clinical features of a thyroglossal cyst?
Thyroglossal cysts occur in the midline of the neck. They are:
Mobile
Non-tender
Soft
Fluctuant
Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue.
Why do thyroglossal cysts occur?
During fetal development, the thyroid gland starts at the base of the tongue. From here, it gradually travels down the neck to the final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears. When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst. This is called a thyroglossal cyst.
Thyroglossal cyst - investigation and management?
Ultrasound or CT scan can confirm the diagnosis.
What are brachial ccysts?
A branchial cyst is a congenital abnormality that arises when the second branchial cleft fails to form properly during fetal development. This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This space can fill with fluid. This fluid-filled lump is called a branchial cyst. Branchial cysts arising from the first, third and fourth branchial clefts are possible, although they are much rarer.
Presntation and management of brachial cyst
Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.
Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected.
Management of a branchial cyst is either:
Conservative, without any active intervention, where it is not causing problems
Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems
From where do head and neck cancers typically arise?
They are usually squamous cell carcinomas arising from the squamous cells of the mucosa.
Potential areas of head and neck cancers?
Nasal cavity
Paranasal sinuses
Mouth
Salivary glands
Pharynx (throat)
Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)
What is meant by a cancer of unknown primary in head and neck cancer?
Head and neck cancers usually spread to the lymph nodes first.
Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found.
This is called cancer of unknown primary.
What is meant by a cancer of unknown primary in head and neck cancer?
Head and neck cancers usually spread to the lymph nodes first.
Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found.
This is called cancer of unknown primary.
General risk factors for head and neck cancer?
Smoking
Chewing tobacco
Chewing betel quid (a habit in south-east Asia)
Alcohol
Human papillomavirus (HPV), particularly strain 16
Epstein–Barr virus (EBV) infection
HPV also causes cervical cancer. The HPV vaccine (Gardasil) protects against strains 6, 11, 16 and 18.
Red flag symptoms and signs that may indicate 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
Management of gead and neck cancer?
Treatment may involve any combination of:
Chemotherapy
Radiotherapy
Surgery
Targeted cancer drugs (i.e., monoclonal antibodies)
Palliative care
Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.
