Lecture 21- Head and neck cancer Flashcards
What is the blood supply to the thyroid gland?
Arterial
- Superior thyroid artery from External Carotid Artery
- Inferior artery from thyrocervical trunk
Venois
- There is a superior, middle and inferior vein that drain back to internal jugular and brachiocephalic (inferior). Form a venous plexus
What is the course of the recurrent laryngeal nerve?
- From the vagus nerve goes down and back up into tracheooesophageal groove
- Left on arch of aorta and right on subclavian artery
What is the relationship between the superior laryngeal nerve and the thyroid?
What is the relationship between the superior laryngeal nerve and the thyroid?
What surrounds the trachea?
What surrounds the trachea?
What is the main type of cancer that occurs in the head and neck?
squamous cell carcinoma (apart form thyroid cancers)
-
Lip//oral
- includes tongue
-
Pharynx
- oropharnx (inc tonsinl)
- nasopharynx
- hypopharynx
-
Nasal cavity/sinuses
- salivery glands
- parotid
- submandibular
- sunlingual
-
Larynx
- Supraglottis
- Glotiss
- Subglottis
- Thyroid
What are the risk factors for head and neck cancers?
- Male, older age (60-70)
- Smoking, alcohol, betal nut chewing
- Occupation e.g exposure to hardwood
- HPV virus in oropharyngeal cancers
- EBV in nasopharyngeal
- Exposure to sunlight in lip cancers
- Pre-malignant changes
e.g. white patches (leucoplakia) or red patches (erythroplakia) seen on tongue
Thyroid cancer risk factors specifically
- Irradiation exposure (including radioactive iodine and radiation leaks)
- Family history and certain inherited conditions e.g. FAP
- Young lumps or old lumps <20 or <70 years old in thyroid glands are more likely to be malignant
What is happening to the incidence of head and neck cancers and why?
Rising, particulary in 30-40 year old due to HPV, even though smoking has decreased
What is the most common presentation of a head and neck cancer and some other symptoms a patient might present with?
Asymptomatic neck lump (cervical lymphadenopathy)
Also:
- Hoarseness of voice
- Dysphagia
- Difficulty breathing
- Odynophagia (painful swallowing)
- Otalgia with normal ear (pharynx and larynx)
- Mucosal ulceration e.g erythroplakia
- Sudden weight loss
- Excessive coughing
How are head and neck cancers diagnosed?
- Clinical examination and biopsy under ultrasound guidance
- CT/MRI
- Endoscopy for larynx biopsy
How do we stage head and neck cancers?
T: size of tumour and location
N: degree of lymph node involvement
M: presence of distant metastases
Distant metastases (particularly in lung) have poor prognosis and often incurable. Need to stage to choose appropriate treatment
How are head and neck cancers often treated?
- Early stage by surgery or radiotherapy. Lasers or radical neck dissection
- Late stage surgery and adjuvant chemotherapy
- Incurable late stage then palliative
- Need MDT approach as lots of functions, e.g swallowing and talking, lost when surgery
What is a radical neck dissection?
Removal of tumour, all ipsilateral lymph nodes, spinal accessory nerve, IJV and SCM
What are some different specialities that may be on an MDT team to plan for a radical neck dissection?
- Radiologist
- Pathologist
- Oncologist
- Dietician
- Plastic surgeon
- S and L therapist
- Head and neck surgeon
What are palliative care plans for a patient with an incurable laryngeal cancer?
Support with feeding, swallowing, pain, voice rehab
How does an oral cavity (lips and tongue) cancer often present? What sort of cancer will it be?
Squamous cell carcinoma
- Unexplained lump or non-healing lesion e.g leukoplakia
- Side of tongue and lip
- Pain or problems swallowing
- Fixation of tongue
- Risk factors: alcohol, HPV, long term sunlight (lip)
oral cavity cancer investigations
treatment of oral cavity (lips and tongue) cancer
- Small tumours excised and defect repaired
- Radiotherapy
- Large tumours that do not respond to RT may need extensive surgery (hemiglossectomy or total glossectomy)
risk factors of oral cancer
alcohol, HPV, long term sunlight (lip)
How does a pharyngeal cancer often present
often presents late – 25% untreatable at presentation
- Lump (mainly nodal mets or unknown primary)
- Pain- glossopharyngeal nerve
- Problems swallowing
- Pain on swallowing
- Weight loss
- bad breathe
- hearing loss or change
- change in voice
risk factors of pharangeal cancer
hardwood, EBV, HPV, drinking, smoking, betel nut, high salt diet
pharangeal cancer investigations
- imaging with CT +- MRI (include chest)
- may need PET
- biopsy
people with pharangeal cancer will often require
will often require feeding assistance with gastrotomy tubes
Treatment of pharynx cancer
- Small tumours excised and repaired the left
- Radiotherapy
- Larger tumours that do not respond to RT may need extensive surgery (mandibular split or other type of pharngectomy or robotic procedure)
Larynx cancer presentation
- Dysphonia- problems speaking
- Dysphagia
- Referred otalgia
- Globus- abnormal sensation of lump in throat
- Neck lump
- Weight loss
- Cachexia (extreme weight loss and muscle wasting)
Laryngeal cancer investigations
*
- Imaging with CT +/- MRI
- May need PET
- Biopsy
larangeal cancer long term side effects
Often have long term voice issues and/or swallowing problems
laryngeal cancer treatment
- Small tumours may have laser resection or RT
- Medium sized tumours do well with RT and chemo
- Larger tumours that do not respond to RT may need extensive surgery (laryngectomy- remove voicebox and disconnected oral cavity from the airway)
- May need an electrical larynx
What is the difference between a tracheostomy and a laryngectomy?
A tracheostomy is a surgical opening to access the tracheal lumen with the entire larynx remaining intact
With a laryngectomy, the larynx is completely removed
- the trachea is brought to the skin as a stoma, which no longer has any anatomical connection with the oropharyngeal cavity and digestive tract
How does thyroid cancer often present?
- Neck lump (goitre or lymphadenopathy)
- Compressive symptoms, e.g dysphagia
- Voice change
- Thyroid function often unaffected
tracheostomy
- Hole in the windpipe
- Done through the neck and into the windpipe
- Temporary
How do we investigate a suspected thyroid cancer?
Triple assessment
- Clincal full history and examination
- Imaging by ultrasound as superficial
- Biopsy under ultrasound by aspiration for cytology
What is the most common malignancy in the H and N and the thyroid?
- H and N: SCC
- Thyroid: see image PFAM
thyroid PFAM?
- Papillary adenocarcinoma (80%)
- follicular adenocarcinoma (10%)
- medullary carcinoma (5%)
- anaplastic carcinoma (5%)
diagnosis worse as you go down the list
If cancer of the thyroid is confirmed by biopsy what is the next step?
- Thyroidectomy followed by radioactive iodine and radio/chemo
- Can damage superior and recurrent laryngeal nerve
why is radioacitve iodine used in trearment of thyroid cancer
Radioactive iodine- iodine is only used in thyroid gland- very useful to target thyroid
What are some differential diagnoses for a recurrent laryngeal nerve palsy?
