overview of head and neck cancer in brief....

1. Dr.Vinin.N.V
Assistant Professor
RadiationOncology
Malabar Cancer Centre

2.  Head & neck cancer refers to cancers of the UADT
(Upper aero digestive tract)
 Oral Cavity
 Pharynx
 Larynx
 Nasal cavity & Paranasal sinuses
 Salivary glands

3.  Overall, head and neck cancer accounts for more
than 550,000 cases annually worldwide
 Males are affected significantly more than
females with a ratio ranging from 2:1 to 4:1.
 The incidence rate in males exceeds 20 per
100,000 in India.
 Head and neck cancers are common in India and
account for about 30% of cancers in males and
about 13% in females.
 Oral cavity cancers are more common in the
India

4.  Head and neck cancers arise from a variety of
locations and structures within the head and
neck region.
 This region is divided into five sites by which
cancers are classified
1. Oral cavity, which includes the lips, buccal
mucosa, anterior tongue, floor of the mouth,
hard palate, upper gingiva, lower gingiva, and
retromolar trigone .

8. 2. Pharynx, which is divided into the nasopharynx, the
oropharynx, and the hypopharynx.
 The nasopharynx, the narrow tubular passage behind
the nasal cavity, is the upper part of the pharynx.
 The oropharynx, the middle part of the pharynx,
includes the tonsillar area, the tongue base, the soft
palate, and the posterior pharyngeal wall.
 The hypopharynx, which is the lower part of the
pharynx, includes the pyriform sinuses, the posterior
surface of the larynx (postcricoid area) and the
inferoposterior, and inferolateral pharyngeal walls.

11.  3. Larynx is divided into three anatomic
regions: the supraglottic larynx, the glottic
larynx (true vocal cords and the anterior and
posterior commissures) and the subglottic
larynx.

14.  4.Nasal cavity and the paranasal sinuses,
which include the maxillary, ethmoid,
sphenoid, and frontal sinuses.

16.  5. Major salivary glands (parotid,
submandibular, and sublingual) and the
minor salivary glands, which are located
throughout the submucosa of the mouth and
upper aerodigestive tract.

17.  Squamous cell carcinomas account for 90 to 95
percent of the lesions in the head and neck.
 They can be categorized as well differentiated
(greater than 75 percent keratinization),
moderately differentiated (25 to 75 percent
keratinization), and poorly differentiated (less
than 25 percent keratinization) tumors.
 Less common histologies include verrucous
carcinoma (a variant of squamous cell
carcinoma), adenocarcinoma, adenoid cystic
carcinoma, and mucoepidermoid carcinomas.

20.  Smoking : In heavy cigarette smokers, there is a
5- to 25-fold increased risk of cancer compared
with nonsmokers.
 Alcohol : Alcohol consumption independently
increases the risk of cancer in the upper
aerodigestive tract.
 Viral infection
Epstein-Barr virus : A large body of evidence
supports the role of EBV as the primary etiologic
agent in the pathogenesis of nasopharyngeal
carcinoma.

21.  Human papillomavirus
 Epidemiologic and molecular evidence has
established a causal role for HPV, primarily type 16, in
patients with head and neck cancer, particularly those
arising in the base of the tongue and the tonsils.
 HPV associated oropharyngeal cancers are typically
seen in younger men who are nonusers of tobacco
and alcohol.
 Human immunodeficiency virus —There is an
approximately two- to three fold increase in the
incidence of squamous cell carcinoma of the head and
neck in HIV-infected patients.

22.  Betel nut chewing — Betel nut chewing, is an independent risk
factor for the development of squamous cell head and neck
cancer.The effects appear to be synergistic with tobacco and
alcohol.
 Occupational exposure —
 Multiple occupational or environmental toxins have been studied
for potential relationship with head and neck cancer.
 These include the dry cleaning agent perchloroethylene ,
asbestos, pesticides, polycyclic aromatic hydrocarbons , textile
workers, wood workers .
 Formaldehyde is associated with nasopharyngeal cancer and
possibly cancers of the nasal cavity and paranasal sinuses.
 Squamous cell carcinoma of the larynx and base of tongue has
also been associated with exposure to Agent Orange.

23. Field Cancerization
 Field cancerization is an important concept related to
the natural history of head and neck cancer.
 This term describes the diffuse epithelial injury
throughout the head and neck, lungs, and esophagus
that results from chronic exposure to carcinogens.
 Clinically, field cancerization is manifested by the
frequent occurrence of (1) mucosal abnormalities,
beyond the margins of a head and neck cancer, and
(2) second primary tumors within this exposed field.
 The lifetime risk of a patient with head and neck
cancer developing a new cancer is 20% to 40%.

24.  Genetic factors — Multiple genetic factors
and pathways may contribute to an increase
in risk of head and neck cancer, and these
factors may interact with other known risk
factors.
 Two inherited genetic syndromes, Fanconi
anemia and Dyskeratosis congenita, may
greatly increase the likelihood of developing
throat and mouth cancers in people at an
early age.

25.  Radiation — Prior irradiation for either
malignant or benign disease has been linked to
thyroid cancer, salivary gland tumors, squamous
cell cancers, and sarcomas.
 Diet
 Several studies have shown a protective effect
associated with increased consumption of fruits
and vegetables.
 Studies suggest that the risk of nasopharyngeal
carcinoma is increased in frequent consumers of
preserved meats that contain high levels of
added nitrites.

26.  The clinical presentation of head and neck
cancer varies widely depending upon the
primary site
 Oral cavity tumors –
 Patients may present with nonhealing mouth
ulcers, loosening of teeth, dysphagia,
odynophagia, weight loss, bleeding, or referred
otalgia.
 Up to 66 percent of patients with primary
tongue lesions have cervical nodal involvement,
while the incidence is substantially lower in
patients with hard palate and lip cancers.

27.  Oropharyngeal tumors – Presenting complaints can
include pain, odynophagia, bleeding, or a neck mass.
 Nasopharyngeal carcinoma –
 The most frequent presenting complaint is a neck
mass due to regional lymph node metastasis, which
occurs in nearly 90 percent of patients.
 Symptoms due to the primary tumor may include
hearing loss (associated with serous otitis media),
tinnitus, nasal obstruction and pain, and its associated
growth into adjacent anatomical structures, which
can lead to muscle involvement and impaired function
of cranial nerves II toVI.

28. Hypopharyngeal tumors –
 Patients with these tumors often remain
asymptomatic for a longer period and are
therefore more likely to be seen in the later
stages of the disease.
 Dysphagia, odynophagia, otalgia, weight
loss, and neck mass are common presenting
symptoms.

29.  Laryngeal cancer –The symptoms associated
with cancer of the larynx depend upon location.
 Persistent hoarseness may be the initial
complaint in glottic cancers; later symptoms
may include dysphagia, referred otalgia, chronic
cough, hemoptysis, and stridor.
 Supraglottic cancers are often discovered later
and may present with airway obstruction or
palpable metastatic lymph nodes.
 Primary subglottic tumors are rare. Affected
patients typically present with stridor or
complaints of dyspnea on exertion.

30. Sinus tumors –
 Common presenting symptoms of sinus
tumors include epistaxis and unilateral nasal
obstruction.
 Facial and/or head pain may be seen in later
stages, due to pressure or tumor infiltration
into nerves or periosteum.

31.  Initial evaluation —The initial assessment of
the primary tumor is based upon a combination
of inspection, palpation, indirect mirror
examination, and direct endoscopy.
 Physical examination should include careful
assessment of the nasal cavity and oral cavity
with visual examination and palpation of
mucous membranes, the floor of the mouth, the
anterior two-thirds of the tongue, tonsillar
fossae and tongue base, palate, tonsillar fossae,
buccal and gingival mucosa

32.  Visualization of lesions outside the mouth is best
accomplished by mirror examination and/or the use of
a flexible fiberoptic endoscope with the goal of
examining all of the mucosa in the nasopharynx,
oropharynx, hypopharynx, and larynx.
 Other abnormalities that should be specifically
searched for are impairment of vocal cord mobility,
pooling of secretions, asymmetries, and bleeding.
 The appropriate nodal drainage areas are examined
by careful palpation of the neck.
 Examination of the neck for pathologic adenopathy
or other masses is best done according to neck levels.
 Biopsy should be taken from lesions and sent for HPE.

34.  An examination under anesthesia often is performed
to best characterize the extent of the tumor, to look
for synchronous second primary tumors, and to take
biopsies for a tissue diagnosis.This exam is
particularly useful for patients with laryngeal and
hypopharyngeal malignancies.
 Symptom-directed panendoscopy (laryngoscopy,
bronchoscopy and esophagoscopy) reveals a 2.4 to
4.5 percent incidence of second primary tumors of the
upper aerodigestive tract.
 In general, patients with a history of heavy alcohol or
tobacco use should undergo panendoscopy.

35.  Imaging studies may augment the physical exam
and evaluation of squamous cell carcinoma of
the head and neck, particularly for assessing the
degree of local invasion, involvement of regional
lymph nodes, and presence of distant
metastases or second primary malignancies.
 The most common metastatic sites are the
lungs, liver, and bone.
 The most common sites of second primary
malignancies are the head and neck, followed by
the lungs and esophagus.

36.  Fine needle aspiration cytology — Fine needle
aspiration cytology (FNA) is frequently used to
make an initial tissue diagnosis of a head and
neck cancer when a patient presents with a neck
mass (metastatic cervical lymph node) without
an obvious primary mucosal/upper aerodigestive
tract site.
 This technique has high sensitivity and
specificity and a diagnostic accuracy that ranges
from 89 to 98 percent .

37.  Imaging studies — Imaging studies
(computed tomography [CT], magnetic
resonance imaging [MRI], positron emission
tomography [PET], and
integrated PET/CT) are important for
assessing the degree of local infiltration,
involvement of regional lymph nodes, and
presence of distant metastases or second
primary tumors.

38.  CT is particularly useful in upstaging cancers that have
deeper local invasion or infiltration into adjacent
structures that is difficult to detect on physical
examination.
 CT can provide information on invasion of the
preepiglottic space, laryngeal cartilage, paraglottic space
and subglottic extension, and can evaluate
retropharyngeal, parapharyngeal, upper mediastinal, and
paratracheal nodes.
 In addition, bone and cartilage invasion, a criterion for
stageT4 disease, can be more readily detected.

40. Magnetic resonance imaging
 MRI provides superior soft tissue definition
compared with CT .
 MRI can provide more accurate definition of
tumors of the tongue and is more sensitive
for superficial tumors.
 MRI is superior to CT for evaluation of
perineural spread, skull base invasion, and
intracranial extension of head and neck
cancer.

42. Regional nodes
 Imaging by CT or MRI is complementary to the
clinical examination for the staging of the neck lymph
nodes.
 In most studies, CT scanning outperforms MRI for the
detection of pathologic nodal metastases.
 Extracapsular spread of nodal metastasis is an
important prognostic factor that should be assessed
on imaging.

43.  PET and integrated PET/CT — With PET, injected
positron-emitting radionuclides, such as fluorine-18,
are taken up by metabolically or functionally active
tissues. PET images are created by detecting these
emissions by an array of detectors and then using
reconstruction techniques to create a three
dimensional image.
 The most commonly used agent is 18F-
flourodeoxyglucose (FDG), which is taken up into cells
in different concentrations depending on the relative
metabolism of different tissues. It is fairly specific for
tumors because metabolic rates are very high in many
tumors.

44.  PET/CT is accurate for detecting occult
cervical nodal metastases.
 Its main utility is in finding occult distant
metastases, unknown primary lesions, and
synchronous second primary tumors
 Helps in altering radiation fields and doses
for patients who are not undergoing neck
dissection.

47. Evaluation for distant metastases
 A component of the initial staging evaluation for
patients with new or recurrent head and neck
cancer is the search for distant metastases.
 The reported incidence is between 2 and 26
percent and varies based on locoregional
control, nodal involvement (number and
presence of extracapsular extension), primary
site (particularly hypopharynx), histologic grade,
andT stage .

48.  Distant metastases are usually
asymptomatic; the most common sites are
the lungs followed by the liver and bone.
 CT scan is the most sensitive method to
screen for distant metastases in patients with
head and neck cancer, identifying malignant
findings in between 4 and 19 percent of
cases.

49.  Incidence of second and multiple
primaries — At-risk patients (ie, those with
strong tobacco and alcohol use or family
history) are prone to develop second primary
cancers of the upper aerodigestive tract. Such
tumors may be present at presentation or
develop subsequently.

50.  The tumor node metastases (TNM) staging
system of the American Joint Committee on
Cancer (AJCC) and the International Union for
Cancer Control (UICC) is used to classify
cancers of the head and neck.
 T classifications indicate the extent of the
primary tumor and are site specific; there is
considerable overlap in the cervical node (N)
classifications.

51. Tis : Carcinoma in situ
T1: Tumor is 2cm or less in greatest dimension
T2: Tumor is > 2cm ≤ 4cm in greatest dimension
T3: Tumor is > 4cm in greatest dimension
T4a: Tumor invades adjacent structures (cortical
bone , deep extrinsic muscles of tongue, skin of
face)
T4b: Tumor invades masticator space, pterygoid
plates, or skull base or ICA.

52. N0 : No regional nodal metastasis
N1 : Metastasis in single ipsilateral LN,<3 cm in
greatest dimension.
N2a: Metastasis in single ipsilateral LN > 3 cm ≤ 6
cm in greatest dimension.
N2b : Metastasis in multiple ipsilateral LNs, none
more than 6 cm in greatest dimension.
N2c: Metastasis in bilateral or contralateral LNs,
none more than 6 cm in greatest dimension.
N3 : Metastasis in LN > 6 cm in greatest
dimension.

53. Mx : Distant metastasis cannot be assessed
M0 : No evidence of distant metastasis
M1 : Distant metastasis

54. STAGE
O TisN0M0
I T1N0M0
II T2N0M0
III T3N0M0, T1-T3N1M0
IVA T4aN0-N1M0,T1-T4aN2M0
IVB AnyTN3M0,T4b AnyNM0
IVC AnyT Any N M1

55.  Treatment for head and neck cancer is complex
• Variety of tumor subsites.
• Anatomic constraints of the head and neck.
• Importance of maintaining organ function.
 A multidisciplinary approach including
 Surgeons
 Medical oncologists
 Radiation oncologists
 Dentists
 Dieticians
 Rehabilitation therapists

56. EARLY STAGE
 Approximately 30 to 40 percent of patients
with head and neck squamous cell
carcinomas (HNSCCs) present with early
(stage I and II) disease.
 In general, these patients are treated with
either primary surgery or definitive radiation
therapy (RT).

57.  Five-year overall survival in patients with stage I
or stage II disease is typically 70 to 90 percent.
 Both modalities result in similar rates of local
control and survival, the choice is typically based
upon surgical accessibility of the tumor and the
functional outcomes and morbidity associated
with each modality.
 In general, surgery is used as the main modality
of treatment in the oral cavity, whereas RT is
more commonly used in the other mucosal sites.

58. ADVANCED STAGE
 Historically, local therapy alone, ie, primary
surgery or definitive radiation therapy (RT),
for locoregionally advanced (stage III, IVA,
and IVB) head and neck squamous cell
carcinomas resulted in high rates of
locoregional recurrence and considerable
morbidity, including loss of tongue and larynx
function (speech and swallowing).

59. Effective approaches for locoregionally
advanced head and neck squamous cell
carcinomas include
 Primary surgery followed by either
postoperative RT or concurrent
chemoradiation
 Concurrent chemoradiation
 Sequential therapy (induction chemotherapy
followed by concurrent chemoradiotherapy).