Head and Neck Cancer

Aetiology

• Larynx is the most common site

Squamous cell carcinoma

• Most common tumour in the head and neck

• Majority relate to smoking and alcohol

• Can be related to HPV, usually HPV type 16
• Produces proteins E6 and E7 which disrupt p53 and RB pathways respectively, leading to cellular immorality
• Tumours have a distinct appearance and a greatly improved prognosis and sensitivity to therapy

Other cancer types

• Nasopharyngeal carcinoma - South China, related to EBV

• Laryngeal carcinoma - typically cigarettes and alcohol aetiology

• Oropharyngeal carcinoma - in 'West' commonly associated with HPV

• Oral cavity carcinoma - South Asia, chewing tobacco

Typical patient groups

• Male, >55 years with long exposure to cigarettes and alcohol

• HPV related OP SCC - typically non-smoker, higher socio-economic class, multiple sexual partners

Pathophysiology

Histology of SCC

• Depends on grading of tumour

• Well differentiated - epithelial cells with keratinisation and prickle cells

• Poorly differentiated - lacks these characteristics

Route of spread

• Predicable route of lymphatic spread
• Allows targeted investigation to look for local metastasis
• Allows for targeted treatment of involved (or suspected) lymph nodes

• Supra-glottic tumours drain to superior deep cervical nodes

• Glottic tumours (present on the cords) - 95% stay on the cords
• Presents with voice changes/airway obstruction

• Sub-glottic tumours spread to paratracheal nodes
• Present with voice/airway obstruction

Clinical presentation

• Dysphonia - >3 weeks warrants urgent referral for largngoscopy

• Dysphagia - particularly if progressive

• Odynophagia

• (Unilateral) otalgia - if no other cause (not referred pain)

• Neck lump

• Can present with airway obstruction - stridor

Investigations

• US + FNA

• Confirm with panendoscopy and biopsy under general anaethesia
• Direct laryngoscopy, tracheoscopy, oesophagoscopy

• Staging
• CT neck - lymph nodes, larynx
• CT chest - staging e.g. looking for metastasis or second primary tumour
• MRI - nasopharynx and tongue base
• PET - metastases

Management

• Initially symptom control - pain management, rehydarate and improve oral intake if necessary (may need admission)

• Early diagnosis results in better outcomes but patients often present late

Laryngeal cancer

• Depends on TNM classification

• Transoral laser surgery

• Radiotherapy

• >90% 5-year survival

• Partial or total laryngectomy - often curative

• Chemo and radiotherapy

• In both cases will need treatment, either chemo/radiotherapy or surgery

Oropharyngeal cancer

• Depends on TNM classification and HPV status

• Transoral laser surgery

• Radiotherapy

• >90% 5-year survival

• Chemo and radiotherapy

• In both cases will need treatment, either chemo/radiotherapy or surgery

Nasopharyngeal cancer

• Uncommon in UK population unless of South China origin

• Treatment is with (chemo) radiotherapy

• Excellent 5-year survival - stage 1 is 100%, stage 4a is 67%