head and neck cancer staging .. Overview of head and neck tumors

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head and neck cancer staging : Head and neck cancers affect around 60,000 people in the United States each year. Excluding the tumors of the skin and thyroid gland,> 90% of head and neck malignancies are squamous cell carcinomas (epidermoids); among the remaining ones, most are adenocarcinomas, sarcomas and lymphomas.

The most common localizations of cervico-cephalic district tumors are:

  • Larynx (supra-optic, glottal, and subglottic region)

  • Oral cavity (tongue body, floor of mouth, hard palate, buccal mucosa and alveolar ridges)

  • Oropharynx (base of the tongue, palatine tonsils and soft palate)

Less common sites include nasopharynx, nasal cavities and paranasal sinuses, hypopharynx and salivary glands.

Further discussions concerning other sites of head and neck cancers are found elsewhere n and M anual :

  • Intracranial tumors in adults

  • Intracranial tumors in children

  • Thyroid tumors

  • Orbital tumors and tumors affecting the retina

  • Acoustic neuronomas

  • Skin tumors

The incidence of head and neck tumors increases with age. Although most patients are between 50 and 70 years of age, the incidence among younger subjects is increasing. Head and neck cancers are more common among men than women; however, the incidence by gender varies with the anatomical localization and is being modified in relation to the increase in the number of women who smoke.

 

Aetiology

The vast majority, about 85% or more, of patients with head-neck tumors have a history of alcohol, tobacco or both. Strong long-term consumers of tobacco and alcohol have a 40-fold higher risk of developing squamous cell carcinoma. Other possible causes include: the use of snuff or chewing tobacco, exposure to sunlight, X-ray exposure to diagnose the head and neck, certain types of viral infections, unsuitable dental equipment, chronic candida infection and poor oral hygiene. In India, oral cavity cancer is extremely common, probably due to betel chewing (mixture of various substances, also known as paan). Long-term exposure to sunlight and

Patients who have previously been treated with radiation therapy for acne, facial hypertrichosis, enlarged thymus or tonsillar hypertrophy and adenoids are predisposed to develop thyroid carcinomas, salivary glands and benign salivary tumors.

Epstein-Barr virus plays a role in the pathogenesis of rhinopharyngeal cancer, the serum levels of some of its viral proteins could be a marker of recurrence.

The link between human papillomavirus infection (HPV) and squamous cell carcinoma of the head and neck, particularly in oropharyngeal locations, appears to be defined. The increase in tumors related to the human papillomavirus has resulted in a global increase in the incidence of oropharyngeal cancer, otherwise expected to be reduced due to the reduced smoking habits observed over the past 2 decades. The mechanism of virus-mediated oncogenesis may differ from the pathways of tobacco-related oncogenesis. 

 

 

symptomatology

Clinical manifestations of head and neck cancers depend on the location and extent of the tumor. The initial common manifestations of head and neck cancers include: an asymptomatic laterocervical swelling, a painful mucous ulcer, a visible mucous lesion (eg, leukoplakia, erythroplakia), hoarseness and dysphagia.

Subsequent symptoms depend on the location and extent of the tumor and include: pain, paresthesia, nerve paralysis, trismus and halitosis. Ophalgia is a symptom often overlooked and usually represents a pain referred from the primary tumor site. Weight loss caused by dysphagia and odynophagia is also frequently observed.

Diagnosis

  • Clinical evaluation

  • Biopsy
  • Imaging and endoscopy to evaluate the extent of the disease

Routine physical examination (including accurate oral examination) is the best method to detect an asymptomatic cancer early. Screening for oral cancers is facilitated by commercially available “brush” biopsy kits. Any symptoms related to the head-neck area (eg, sore throat, hoarseness, otalgia) that persists from > 2-3 weeks should be quickly sent to the attention of an ENT specialist who will perform laryngoscopy with flexible optical fibers to examine the larynx and the pharynx.

 

The diagnosis of certainty requires biopsy. Fine needle aspiration can be used to investigate a cervical mass ; it is a well-tolerated procedure that, unlike open-ended biopsy, does not affect future treatment options. Oral lesions are evaluated with an incisional biopsy or exfoliative cytology. Locations at the level of rhinopharynx, oropharynx and larynx are investigated by endoscopic biopsy.

Image methods (CT, MRI, or PET / CT) are useful for defining the extent of the primary tumor, the involvement of adjacent structures and cervical lymph nodes.

Staging

Head and neck tumors are staged ( Staging of head and neck tumors ) based on the size and location of the primary tumor (T), the number and size of metastases to the cervical lymph nodes (N) and the presence of distant metastasis (M). Clinical staging usually requires imaging by CT, MRI or both; PET is often used.

 

Staging of head and neck tumors

Stadium

Tumor (maximum penetration)

Metastasis to regional lymph nodes

Remote metastasis

THE

T1

N0

M0

II

T2

N0

M0

III

T3 o

N0

M0

T1-3

N1

M0

VAT

T1-3

N2

M0

T4a

N0-2

M0

IVB

T4b

Every N

M0

Every T

N3

M0

IVC

Every T

Every N

M1

TNM classification: T1  2 cm maximum size; T2 = 2-4 cm or involvement of 2 areas within a specific site; T3 > 4 cm or involvement of 3 areas within a specific site; T4 = invades adjacent structures (4a defines moderately advanced local disease and 4b very advanced local disease).

N0 = none; N1 = a lymph node  3 cm; N2 = a lymph node between 3 and 6 cm or more lymph nodes; N3 = a lymph node > 6 cm.

M0 = none; M1 = present.

Prognosis

The prognosis in head and neck cancers varies widely depending on the size of the primary tumor, the primary site, the etiology and the presence of regional or distant metastases. Generally, the prognosis is favorable if the diagnosis is early and treatment is timely and appropriate.

Head and neck tumors first show a local invasion and then a metastasis to the cervical regional lymph nodes. Diffusion to locoregional lymph nodes is partially related to tumor size, extent and aggressiveness and reduces overall survival by almost half. Remote metastases (most of the lungs) tend to occur later, usually in patients with advanced disease. Remote metastases greatly reduce survival and are almost always incurable.

The advanced local disease (which constitutes a criterion for defining advanced stage T) with invasion of the adjacent muscular, bone or cartilaginous structures significantly reduces the possibility of healing. Perineural diffusion, as evidenced by pain, paralysis or numbness, is typical of aggressive tumor forms, often associated with lymph node metastasis and has a less favorable prognosis than lesions without perineural invasion.

With adequate treatment, 5-year survival can reach 90% for stage I, from 75 to 80% for stage II, from 45 to 75% for stage III and up to 50% for some stage IV tumors. . Survival rates vary widely depending on the primary site and the aetiology. Stage I laryngeal tumors have an excellent survival rate compared to tumors in the other sub-sites. Oropharyngeal tumors caused by human papillomavirus seem to have a significantly better prognosis than oropharyngeal tumors caused by tobacco or alcohol. Because the prognosis between HPV-positive and HPV-negative oropharyngeal tumors is different, all tumors of the oropharynx should be systematically investigated for the presence of human papillomavirus.

Treatment

  • Surgery and / or radiotherapy

  • Possible chemotherapy

The main treatments for head and neck cancer are surgery and radiotherapy. These modalities can be used individually or in combination and with or without chemotherapy. However, exclusive chemotherapy is almost never used as a primary treatment for healing purposes. Many tumors, regardless of their location, respond in a similar way to surgery and radiotherapy, thus allowing to decide treatment also based on other factors, such as patient preferences or morbidity depending on the specificity of location.

However, for certain sub-assays, there is a clear superiority of one of the therapeutic modalities. For example, surgery is preferable for early-stage disease involving the oral cavity, as radiation therapy can potentially cause a mandibular osteoradionecrosis. Endoscopic surgery has become more common; in selected cases of head and neck cancer, it demonstrates healing rates similar to open surgery or radiotherapy, and its morbidity is significantly lower. Endoscopic approaches with laser scalpels are usually used for laryngeal surgery.

If radiotherapy is chosen as a first-line therapy, it is administered on the primary site and sometimes bilaterally on the cervical lymph nodes. The treatment of the lymph nodes, both surgical and radiotherapeutic, is determined by the primary site, by histological criteria and by the risk of lymph node metastasis. Initial lesions often do not require treatment of the lymph nodes, as opposed to more advanced lesions. Locations that are rich in lymphatic vessels (eg, oropharynx, supraglottis) usually require radiotherapy on the lymph nodes regardless of the stage, whereas sites with fewer lymphatic vessels (eg, larynx) usually they do not need radiotherapy on the lymph node stations for early stage disease. Modulated intensity radiotherapy (IMRT) allows the

Advanced stage tumors (stage III and IV) often require multimodal treatment, which may include a combination of chemotherapy, radiotherapy and surgery. Invasion of bone or cartilaginous structures involves surgical resection of the primary site and usually of regional lymph nodes, given the high risk of lymph node diffusion. If the primary T is surgically treated, the radiation treatment on the lymph nodes is reserved for high-risk situations such as the presence of multiple lymph node metastases or with extracapsular extension. Postoperative radiotherapy is usually preferable to preoperative radiotherapy because irradiated tissues heal with difficulty.

Recent studies have shown that the addition of chemotherapy to adjuvant radiotherapy in the neck improves regional control and survival. However, this combined approach involves significant added risks, such as the onset of dysphagia or myelosuppression; therefore the decision to associate chemotherapy must be carefully evaluated.

Advanced squamous cell carcinoma without bone infiltration is often treated with concomitant radiotherapy chemotherapy. Although it involves organ rescue, the combined chemo-radiotherapy treatment doubles the rate of acute toxicity, especially severe dysphagia. Exclusive radiotherapy is indicated in debilitated patients with advanced disease who have contraindications to chemotherapy and an excessively high anesthetic risk.

Primary chemotherapy is reserved for radiosensitive tumors, such as Burkitt’s lymphoma, or patients with diffuse metastases (eg, hepatic or pulmonary involvement). Cisplatin, fluorouracil, bleomycin and methotrexate are helpful in palliative pain treatment and reduce tumor burden in patients who can not be treated by other means. The initial response to such treatment may be good but it is not lasting and the tumor pathology almost always relapses.

Since the treatment of head and neck cancers is very complex, it is essential that treatment planning be carried out within a multidisciplinary group. Ideally, each patient must be assessed collegially by the specialists involved in the diagnostic-therapeutic process, together with radiologists and pathologists, so as to plan the most appropriate treatment on a case-by-case basis. Once the treatment has been determined, it is useful for the patient to belong to a multidisciplinary group comprising ENT and plastic surgeons, medical oncologists and radiotherapists, speech therapists, dentists and nutritionists.

Plastic and reconstructive surgeons play an increasingly important role because the use of free flap transfer techniques has enabled the implementation of functional and cosmetic restorations that significantly improve the quality of life of patients following invasive or demolition procedures. Common donor sites used for reconstruction include the fibula (often used to reconstruct the mandible), the radial portion of the forearm (commonly used for the tongue and the floor of the oral cavity) and the anterolateral of the thigh (often used for the reconstruction of the larynx or pharynx).

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Treatment of tumor recurrence

The management of tumors that recur after treatment is complex and has potential complications. A palpable mass or an ulcerated lesion with edema or pain in the primary site after therapy strongly suggests a persistent tumor. Such patients need CT (in thin scans) or MRI.

In local recurrences after surgical treatment, all the cicatricial planes and the reconstructive flaps are removed together with the residual tumor. You can subject the patient to radiotherapy, chemotherapy or both, but they are of limited effectiveness. Patients with recurrence after radiation therapy are best treated with surgery. However, some patients may benefit from additional radiation treatments, but this approach has a high risk of adverse effects and should be conducted with caution.

Symptom control

Pain is a frequent symptom in patients with head and neck cancer and must be adequately addressed. Palliative surgery or palliative radiotherapy can temporarily relieve pain and in 30 to 50% of patients; chemotherapy can produce an improvement that lasts for an average of 3 months. A gradual approach to pain management, as recommended by the WHO, is crucial for symptom control. A specialist in analgesic therapy will better manage the cases of critical pain.

Pain, difficulty in feeding, suffocation from secretions and other problems make the proper treatment of symptoms essential. The directives for the patient about such contingencies must be clarified from the beginning ( Advance Directives ).

Adverse effects of therapy

All cancer treatments involve potential complications and expected sequelae. Since many treatments have similar healing rates, the choice of mode is largely based on the real or perceived differences of sequelae.

Although it is commonly thought that surgery causes more morbidity, many procedures can be performed without significantly affecting the appearance or functionality. More and more complex reconstructive procedures and techniques such as prosthetics, grafts, pedunculated limbs, regional and complex free flaps are able to bring the appearance and function of the organ to a condition that is close to normal.

The toxic effects of chemotherapy include: malaise, severe nausea and vomiting, mucositis, transient loss of hair, gastroenteritis, hemopoietic and immune suppression and infection.

Radiation therapy for head and neck cancers has several adverse effects. The function of each salivary gland in the irradiated area is permanently destroyed by a dose of about 40 Gy, leading to xerostomia which, in turn, markedly increases the risk of dental caries. More recent radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT), can, in selected cases, minimize or eliminate toxic effects on the parotid glands.

The blood supply to the bones, in particular the mandible, is also compromised by administering doses > 60 Gray, with possible osteoradionecrosis (Dental therapy in patients with systemic disorders: Radiotherapy). In this condition, the dental extraction sites yield, losing bone and soft tissues. Therefore, any necessary dental treatment, including sanding, fillings and extractions, must be done before radiotherapy. Every tooth in poor condition, which can not be recovered, must be extracted.

Radiotherapy can also cause oral mucositis and dermatitis in the overlying skin, which can lead to fibrosis of the dermis. Loss of taste (ageusia) and impaired smell (dysosmia) may occur, which are usually reversible.

Prevention

Removing risk factors is essential; all patients must stop using tobacco and limit alcohol consumption. This also contributes to the prevention of relapses in patients with laryngeal carcinoma. A new primary tumor develops in about 5% of patients / year (up to a maximum risk of about 20%); the risk is lower in those who stop consuming tobacco.

Current vaccines against human papillomavirus are directed against some strains implicated in oropharyngeal cancer; it can be expected that the current vaccination campaigns among children may reduce the incidence of this cancer.

Cancer of the lower lip can be prevented by the use of sunscreens and by the suspension of the tabagic habit. Because 60% of head and neck cancers are advanced (stage III or IV) at the time of diagnosis, the most promising strategy for reducing morbidity and mortality is a careful routine oral examination.

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