Head & Neck Cancers Flashcards
Which cancers are included under the umbrella term “Head and neck cancers”?
- Oral cavity cancers
- Cancers of the pharynx including oropharynx, hypopharynx and nasopharynx
- Cancers of the larynx
What are oral cavity cancers?
Oral cavity cancers include cancers of lips, tongues, floor of the mouth, alveolar ridge, hard palate or buccal lining.
=> 90% are squamous cell carcinomas
What are the risk factors?
Who does it commonly affect?
- Smoking
- Alcohol
- Betel nut (esp. in indian subcontinent)
- Chronic dental infection
- Immunosuppression
=> typically seen in middle age / older male patients
=> Increasingly seen in women due to increased smoking
What are the signs and symptoms of oral cavity cancers?
- Painless ulcer / lump
=> pain is a late symptom - Impaired speech and swallowing due to increasing size of tumour
- Erythroplakia - red, erythematous, velvety mucous membrane
- Leukoplakia (white) or mixed red/white lesions (speckled leukoplakia)
- Lichen planus
- Non-healing ulcer
- Neck swelling if metastases present
- Discolouration
Carcinoma of the lip:
=> most curable carcinoma in head & neck
=> sun exposure = well established link
=> lower lip most affected - 90%
Risk factors:
=> male,
=> fair skin,
=> older patient
Treatment:
=> Small tumours - excision and primary closure
=> Larger tumours - local skin flaps for reconstruction
Carcinoma of the oral tongue:
=> incidence is increasing in younger adults
=> lateral border + anterior 2/3 of tongue commonly affected
=> presents with a persisting ulcer
Treatment:
=> Smaller tumours - surgical excision
=> Advanced cancer - resection of primary lesions, neck dissection and post-operative radiotherapy
What are the risk factors for carcinomas of the pharynx (nasopharynx, oropharynx and hypopharynx)?
- Smoking
- Alcohol
- Viruses:
=> Oropharynx - human papilloma virus 16 & 18
=> Nasopharynx - epstein barr virus
- Radiation
Nasopharynx cancer:
=> rare tumour
=> most common in south asian and north asian population
=> EBV plays a major causative role
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What are the signs & symptoms of nasopharynx cancer?
=> Cervical lymphadenopathy
=> Ear pain
=> Secretory otitis media
=> Hearing loss
=> Persistent unilateral otitis media with effusion and no preceding upper respiratory tract infection
=> Cranial nerve palsies (CN3,4,5)
=> Epistaxis
=> Nasal discharge / obstruction
=> Changes in smell
What is nasopharyngeal angiofibroma?
How is it diagnosed and managed?
Epistaxis in young adult secondary to juvenile nasopharyngeal angiofibroma
=> arises in lateral wall of the nose in young males
=> benign but locally invasive and highly vascular tumour
=> if suspected, do NOT biopsy
=> diagnosis by imaging
=> management by surgical resection
What are the investigations for nasopharyngeal cancers?
Nasopharyngeal cancers are managed by combined chemotherapy and radiotherapy.
- Detailed head & neck exam
- Nasendoscopy
- Formal biopsy
- Fine needle aspirate of neck lymph nodes
- Imaging
- MRI (better to assess soft tissue involvement)
- CT (better to assess bony involvement)
What are oropharynx cancers?
Tumours of the tongue base (posterior 1/3 of the tongue) and tonsils
=> 70% of tonsillar tumours = squamous cell cancers
=> minority of tonsil tumours = lymphomas
What are the symptoms of oropharynx cancers?
- Unilateral painless tonsillar swelling
- Hx of throat discomfort with worsening dysphagia
- Referred otalgia
- ‘Lump in throat’ sensation or evidence of metastatic cervical lymphadenopathy
- Trismus = red flag for surrounding structure tumour infiltration
What are the investigations and management for oropharynx cancer?
Investigations:
=> Detailed head & neck exam
=> Panendoscopy + biopsy
=> Fine needle aspirate of neck nodes
=> Imaging - MRI for margins of tumour + CT for staging
Management:
=> Surgery ± radiotherapy / chemotherapy
=> Chemoradiotherapy
What are hypopharynx cancers?
Hypopharynx tumours are squamous cell carcinomas
=> metastases common
=> typically affects men 55-70 years old with a history or tobacco use / alcohol use
What are the symptoms of hypopharynx cancers?
- Cervical lymphadenopathy
- Pain that radiates from throat to ear
- Sore throat
- Painful swallowing (odynophagia)
- Voice changes
- Paterson-Brown-Kelly syndrome
=> dysphagia
=> hypo chromic microcytic anaemia
=> oesophageal webs
=> potential development of postcricoid carcinoma
What are the investigation and management for hypopharynx cancer?
Investigations:
=> Endoscopy + biopsy
=> Pharyngo-oesophagoscopy
=> Imaging / barium swallow / MRI / CT for staging
Management:
=> Early cancers (rare) - surgery + radiotherapy
=> Advanced cancers - surgery + radiotherapy ± neoadjuvant chemotherapy
*many hypopharynx cancers = incurable at presentation => supportive / palliative care
What is larynx carcinoma?
90% of laryngeal carcinoma are squamous cell carcinomas and can be subdivided into:
=> Supraglottic (27%)
=> Glottic (69%) - most common
=> Subglottic (4%)
More common in men and elderly
What are the risk factors for laryngeal cancer?
Smoking (most important)
Alcohol (cumulative risk increases with smoking)
What are the signs and symptoms of laryngeal cancer?
- Hoarseness - most common presentation; commonest in glottic cancer
=> progressively worsening over 6-12weeks - Noisy breathing/stridor
=> late presentation in supraglottic cancer - Cough
- Haemoptysis
- Odynophagia
- Dysphagia
=> commonest in supraglottic carcinoma - Neck lymphadenopathy
=> commonest in supraglottic carcinoma
What investigations are carried out for laryngeal cancer?
- Oral cavity, ENT and neck examination
- Flexible nasoendoscopy
- Microlaryngoscopy for biopsy
- CT neck and chest for staging
- MRI neck and PET CT (sometimes)
- TNM classification for staging
How is laryngeal cancer managed?
Depends on TNM staging of tumour
=> Smaller tumours (T1-T2) treatment is single modality either radiotherapy or endoscopic laser excision
=> Larger tumours (T3-T4) treatment is multi-modality either larynx sparing i.e. chemoradiotherapy or laryngectomy with post-op radiotherapy
All suspected head & neck cancers should be referred to the urgent 2 week cancer referral pathway in ENT
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