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Head and neck cancers

Head and neck cancers ( HNC ) ) represent 3rd most common cause 
of cancer death worldwide HNC is the 5th most frequent cancer worldwide (or 6th as per Over 30 specific sites in the head & neck region can be involved and the vast majority ( > 90 % ) are squamous cell carcinomas ( HNSCCs ) and the disease typically appears in the oropharynx , oral cavity , hypopharynx or larynx HNSCC originate from the mucosal epithelial cells that line the oral cavity , pharynx , larynx and the sinonasal tract The tumour can vary in location , pathophysiology , biological behavior and sensitivity to treatment Global burden of HNC ( in 2018 ) -650,000 new cases and 350,000 deaths worldwide / year and major proportion of regional malignancies in India In the UK in 2014 there were 11,400 new cases Men suffer more with male : female ration of 7 : 1 Median age of non-virally associated HNSCC is 66 yrs whereas for HPV associated oropharyngeal cancers and EBV associated nasopharyngeal cancer is 53 yrs & 50 yrs respectively The incidence of HNC has increased over the last few decades with an increase in use and exposure to tobacco and alcohol ( and expected to ↑↑ by 30 % by 2030 )

Smoking and alcohol are the strongest independent risk factors and have synergistic or multiplicative correlation Heavy drinkers who also smoke heavily ( foe e.g < 2 pack/day ) the risk of oral cancer is over 35 times more than those who do not smoke or drink About 90 % of patients with HNSCC have a h/o cigarette smoking- risk is related to frequency ,intensity and duration of It has been shown that stopping smoking for even a short period for e,g 1-4 yrs leads to a HNC risk reduction of about 30 % compared with current smoking , it reduces the risk of laryngeal cancer by 60 % after 10-15 yrs and after 20 yrs the risk is similar to a non smoker Pipe and cigar smoking is associated with even higher risk excess risk of oral cancer Betel nut chewing ( with or without tobacco ) is strongly associated with oral and pharyngeal cancers
○ In India and Sudan 50% to 60 % of oral cavity cancers are due to smokeless tobbacco Alcohol- is also an independent risk factor for HNC- it increases particularly risk of hypopharyngeal cancers Alcohol consumption is an important risk factor for cancers of the mouth and pharynx and risk of oral cancer increases with amount of alcohol consumed HPV ( Human papilloma virus ) is also being increasingly recognised as a risk factor for HNC particularly cancer of the pharynx Carcinogenic air pollutants including organic and inorganic chemicals as well as particulate matters are risk factors for HNCC Regular consumption of fruits and vegetables has a protective effect Laryngeal 
cancers include 
tumours of supraglottis glottis subglottis. Hypopharyngeal cancers
 include tumours of-post-cricoid area pyriform sinus posterior pharyngeal wall Oropharyngeal cancers 
include tumours of base of tongue tonsil soft palate Oral cavity cancers 
include tumours of buccal mucosa retromolar triangle alveolus hard palate anterior 2/3rd of the tongue floor of the mouth mucosal surface of the lip. Bleeding from mouth Hoarseness of voice Dysphagia Odynophagia Ulcerative growth in mouth Throat pain Neck / cervical swelling Dyspnoea Trismus Headache / earache Nasal obstruction / discharge. persistent unexplained neck lump persistent hoarseness particularly with sore throat earache with no local abnormalities / unexplained thyroid swelling in a prepubertal patient thyroid swelling with other aspects as
○ h/o neck irradiation
○ family h/o endocrine tumour
○ unexplained hoarseness
○ cervical lymphadenopathy
○ patiet is 65 or > cranial neuropathies orbital mass solitary nodule which is increasing in size unexplained swelling of the lip in the oral cavity or ulceration all red / white or mixed red and white patches of the oral mucosa that are painful , swollen or bleed and are consistent with erythroplakia or Erythro leukoplakia dysphagia or odynophagia nerve palsies – facial / hypoglossal / ocular unilateral swelling which is hard , firm or rubbery irregular pigmented mucosal area tongue numbness or fixation.

Examine neck , salivary glands and facial bones Check nerve function ( particularly those with facial pain ) Examine all parts of mouth with good illumination Oral cavity examination- 
○ lateral tongue ○ floor of mouth ○ gingivae ○ lips and vestibule ○ hard and soft palate ○ oropharynx Palpate for any masses Encourage to have annual dental check ups

Smoking status ( current ? ex ) Alcohol consumption – socioeconomic status Weight loss Unilateral nasal obstruction with blood stained , watery discharge Paan / betel Quid / Khat chewing Diet – ? low in fruit and vegetable consumption Genetics ( sufferers of Fanconi anaemia -rare – have a 500- 700 fold ↑↑ ed risk of developing HNSCC ) HIV/ AIDS / HPV H/O previous HNC Previous cancer treatment Immunosuppressed.

represent 1/3rd of HNC’s presentation , pattern of spread and treatment options would vary based on the site/ size of the cancer tumour of the glottis for e,g would typically present at an early stage as they manifest as hoarseness 
( due to vocal cord immobility or fixation ) tumours of the supraglottis can present later with symptoms of pain , hoarseness or swallowing difficulty majority ( about 98 % ) of laryngeal cancers arise either in supraglottic or glottic regions with glottic cancers 3 times more common than supraglottic cancers can be diagnosed by inspection of the larynx with a fiberoptic laryngoscope and early stage disease is highly curable with larynx-preserving whereas late stage disease has a worse outcome requiring multimodal approach and is often less larynx-preserving Consider a USC in people over 
45 and over with
 persistent unexplained hoarseness

OR
 an unexplained lump in neck.

Oral cancers -include cancers of lips , tongue , gingiva ,mouth floor , parotid and salivary glands often present late with poor prognosis and survival that has not changed much in the last few yrs wide geographical variation -in parts of India this can represent more than 50 % of all cancers , Consider a suspected cancer pathway referral for oral cancer in people with
○ unexplained ulceration in the oral cavity lasting more than 3 weeks OR
○ a persistent and explained lump in the neck
 Consider an urgent referral ( appt within 2 weeks ) for assessment for possible oral cancer by a dentist in people who have either
○ a lump on the lip or the oral cavity OR
○ a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
 Consider a suspected cancer pathway referral by the dentist for oral cancer 
○ a lump on the lip or in the oral cavity consistent with oral cancer OR
○ a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Thyroid cancer -incidence of thyroid cancers have increased in the last 3 decades
( possibly due to ↑↑ use of imaging studies ) about 5 % of detected thyroid nodules can be malignant thyroid cancer is a malignancy of the thyroid parenchymal cells seen more commonly in women , seen more often in the age group 45-54 yrs with a mean age of diagnosis at 50 follicular cells give rise to differentiated thyroid cancer ( DTC ) and parafollicular cells to medullary thyroid carcinoma ( MTC ) risk factors for thyroid cancers include
○ h/o radiation to the head and neck region
○ a family h/o thyroid cancer or thyroid disease
○suspicious US findings
○ lymphadenopathy
○ h/ goiter
○ female sex and Asian ancestry. Consider a suspected cancer pathway referral for thyroid cancer 
in people with an unexplained thyroid lump.

Tonsillar cancer tonsils are the most common site of oropharyngeal cancer the rise in cases of tonsilar cancer has been attributed to the viral epidemic of HPV in the Western world presentation can be variable with c/o sore throat , unilateral otalgia or sensation of a mass in the throat with trismus indicating local invasion ( other presenting symptoms can include weight loss , odynophagia , dyaphagia and persistent hoarseness ) individuals at increased risk of tonsillar cancer include
○ previous h/o HPV related anogenital malignancy
○ women over the age of 50 with a h/o in situ cervical cancer
○ husbands of women with in situ or invasive cervical cancer vast majority of cervical cancers are SCC’s

Lethal disease due to 
○ low awareness
○ presentation may lack specific visible or palpable signs
○ late detection in advanced stages Associated with significant psychological distress and compromised QoL
◘ potential disfigurement and communication problems
◘ survivors have the 2nd highest rate of suicide after those with pancreatic cancer A UK study has shown that amongst referrals from primary care for cancers, laryngeal cancer has the 5th-longest primary care interval ( ie time from diagnosis to referral)

Usually multimodal for eg
○ surgery
○ chemoradiotherapy ( CRT )
○ monoclonal antibody use 
( e.g cetuximab for pharynx and larynx cancers ) Surgical bloc dissection Specialists from several specialities can be involved in management HNC’s as
○ otolaryngologists
○ maxillofacial surgeons
○ plastic and reconstructive surgeons
○ endocrine surgeons
○ general surgeons with special interests
○ speech and language therapy
○ dietitians
○ specialist nurses Several biological markers have been investigated with CD44 , CD133 and ALDH1 being the most extensively validated and associated with prognostic significance

Patient information

National Cancer Institute– head and neck cancers fact sheet for patients https://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet

Cancer Research UK on head and neck cancers –https://www.cancerresearchuk.org/about-cancer/head-neck-cancer

A very valuable resource from Christie NHS Foundation Trust-has links to several useful publications https://www.christie.nhs.uk/patients-and-visitors/services/head-and-neck-team/links-to-further-information-about-head-and-neck-cancer

Laryngeal cancer info from Christie https://www.christie.nhs.uk/patients-and-visitors/your-treatment-and-care/types-of-cancer/laryngeal-cancer

Onco-Link on laryngeal cancer https://www.oncolink.org/cancers/head-and-neck/head-and-neck-cancers/laryngeal-cancer/all-about-laryngeal-cancer

Support for patients with laryngeal cancer https://www.throatcancerfoundation.org/support/

Oral cancer information and support https://oralcancerfoundation.org/understanding/

Charity raising awareness of mouth cancer in UK with some very simplfied leaflets to download  https://www.mouthcancerfoundation.org/

Patient guide radiotherapy for cancer in head and neck region from Oxford University Hospitalshttps://www.ouh.nhs.uk/patient-guide/leaflets/files/12814Pradiotherapy.pdf

 

References

  1. Gil Z, Fliss DM. Contemporary management of head and neck cancers. Isr Med Assoc J. 2009 May;11(5):296-300. PMID: 19637508. ( Abstract )
  2. Shephard EA, Parkinson MA, Hamilton WT. Recognising laryngeal cancer in primary care: a large case-control study using electronic records. The British Journal of General Practice : the Journal of the Royal College of General Practitioners. 2019 Feb;69(679):e127-e133. DOI: 10.3399/bjgp19x700997.
  3. Cheshire and Merseyside Local Dental Newtwork Oral Cancer Care Local Guide Prevention – Early Detection Referral final-NHS-ORAL-CANCER-CARE-with-Acknowledgements.pdf (dental-referrals.org)
  4. SIGN Diagnosis and management of head and neck cancer A National Guideline CancerPbDiagnosisHeadAndNeckCancer.pdf (uhb.nhs.uk)
  5. Galbiatti AL, Padovani-Junior JA, Maníglia JV, Rodrigues CD, Pavarino ÉC, Goloni-Bertollo EM. Head and neck cancer: causes, prevention and treatment. Braz J Otorhinolaryngol. 2013 Mar-Apr;79(2):239-47. English, Portuguese. doi: 10.5935/1808-8694.20130041. PMID: 23670332.
  6. Alsahafi, Elham et al. “Clinical update on head and neck cancer: molecular biology and ongoing challenges.” Cell death & disease vol. 10,8 540. 15 Jul. 2019, doi:10.1038/s41419-019-1769-9 ( Abstract )
  7. Dhull, Anil Kumar et al. “Major Risk Factors in Head and Neck Cancer: A Retrospective Analysis of 12-Year Experiences.” World journal of oncology vol. 9,3 (2018): 80-84. doi:10.14740/wjon1104w
  8. Shaw, R, and N Beasley. “Aetiology and risk factors for head and neck cancer: United Kingdom National Multidisciplinary Guidelines.” The Journal of laryngology and otology vol. 130,S2 (2016): S9-S12. doi:10.1017/S0022215116000360
  9. Epidemiology, Risk factors and Pathogenesis of Squamous Cell Tumours Risk Factors | OncologyPRO (esmo.org)
  10. Johnson, D.E., Burtness, B., Leemans, C.R. et al. Head and neck squamous cell carcinoma. Nat Rev Dis Primers 6, 92 (2020). https://doi.org/10.1038/s41572-020-00224-3 ( Abstract ) https://doi.org/10.1038/s41572-020-00224-3
  11. Lee K, Anastasopoulou C, Chandran C, et al. Thyroid Cancer. [Updated 2021 Jul 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459299/
  12. Nguyen, Quang T et al. “Diagnosis and treatment of patients with thyroid cancer.” American health & drug benefits vol. 8,1 (2015): 30-40.
  13. Rivera, César. “Essentials of oral cancer.” International journal of clinical and experimental pathology vol. 8,9 11884-94. 1 Sep. 2015
  14. Jones, T M et al. “Laryngeal cancer: United Kingdom National Multidisciplinary guidelines.” The Journal of laryngology and otology vol. 130,S2 (2016): S75-S82. doi:10.1017/S0022215116000487
  15. Koroulakis A, Agarwal M. Laryngeal Cancer. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526076/
  16. Tonsillar Cancer incidence prevalence of HPV and Survival Lalle Hammarstedt Karolinska Institute Stockholm 2008 thesis.pdf (ki.se)
  17. Williamson AJ, Mullangi S, Gajra A. Tonsil Cancer. [Updated 2021 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537238/

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