Head and neck cancer
Causes and risk factors
As mentioned above, long-term alcohol and/or tobacco smoke consumption are risk factors, in addition to other contributing factors such as poor oral hygiene, improper placement of dentures leading to mucosal trauma and ulceration, and inhalation of dust and toxic substances. Heredity is rare.
Papillomavirus infections (HPV 16-18) are a risk factor for some oropharyngeal tumors, particularly carcinoma of the palatine tonsils and base of the tongue. To date, detection of the virus integrated into the tumor cell represents an independent prognostic factor associated with a more favorable prognosis, but does not influence treatment choices outside of clinical trials.
Which are the symptoms?
Symptoms for head and neck tumors depend on the anatomical location of the disease. However, in many cases, these tumors develop with minor and trivial symptoms. Symptoms that may indicate this diagnosis are:
painful mouth ulcers that do not respond to conventional medical treatment
decreased tone of voice (dysphonia)
difficulty swallowing (dysphagia)
persistent (often painless) neck swelling
slight but persistent bleeding from the mouth or nose.
In infiltrative forms, pain is often present, which can be felt in nearby organs (for example, in the ear).
Dysphonia is typical for tumors of the vocal cords, and difficulty in swallowing solid food occurs with vegetative forms of damage to the upper digestive tract. With tumors of the nasal cavities and paranasal sinuses, breathing difficulties, small persistent nosebleeds may occur.
Tumors of the nasopharynx lead to a change in the timbre of the voice in vegetative forms, muffling of hearing, premature swelling of the lymph nodes of the neck.
- painful mouth ulcers
- persistent neck swelling
- slight but persistent bleeding from the mouth or nose
How is it diagnosed?
It is important not to ignore the appearance of ulceration or swelling in the mouth and neck. Therefore, early diagnosis is very important. With neoplasms detected at an early stage and without affection of the lymph nodes, the percentage of cure is from 75 to 100% of cases. For this purposer, our institute has at its disposal a multimodal equipment of the latest generation:
rigid (Fig. 6) and flexible fiber-optic video endoscopic systems with the ability to integrate with NBI (narrow band imaging) illumination, which is especially useful for detecting altered mucosal vascularization patterns, video recording systems, archiving and image processing, video stroboscopy systems (Fig. 8).
When the disease is diagnosed at an advanced stage, i.e. stage III-IV, the prognosis worsens sharply, the survival rate for 5 years is about 40%. Unfortunately, most cases of head and neck tumors are diagnosed at an advanced stage.
Diagnosis of a head and neck tumor is based on clinical and instrumental studies that can confirm or not confirm the presence of the presumed disease. In the presence of the above symptoms or signs, the family doctor will refer the patient for a thorough examination by specialists and, possibly, to determine the list of tests that must be performed to make a diagnosis.
The most common diagnostic and staging procedures are:
Clinical examination: it can be performed by examining the oral cavity or, in the case of structures not accessible to the naked eye, using an optical fiberscope. Examination with a fiberscope is an endoscopic method (which means "looking inward"), because it uses a flexible tube equipped with its own illumination at the end, which is inserted into the nasal cavity, which allows examining the entire otorhinolaryngological area, which cannot be evaluated from the outside (Fig. 9). It is especially useful for examining the pharynx, larynx, and paranasal sinuses. The use of a fiberscope allows direct biopsy in many patients. Clinical examination should also include palpation of the suspected lesion to assess the extent of disease infiltration. Finally, a careful examination of the lymph node groups by palpation of the neck is necessary to assess the possible spread of the disease to the lymph nodes.
Radiography plays a key role in diagnosis, and examinations such as ultrasound, computed axial tomography (CAT), nuclear magnetic resonance (NMR), positron emission tomography (PET) and CAT-PET are performed. These examinations are necessary for accurate staging of the disease, guidance in treatment and subsequent evaluation of the results.
CT (computed tomography) or MRI (magnetic resonance imaging), both with contrast medium, are fundamental procedures because they can assess the spread of the disease by providing detailed information about infiltration in the depth and lymph nodes of the neck.
Chest radiography: it is necessary in order to exclude the presence of metastases in the lung or to exclude the simultaneous presence of lung cancer; it is also useful for preoperative assessment of a patient’s condition.
PET (Positron Emission Tomography): the injection of a radionuclide (a sweetened radioactive liquid to which tumor cells avidly respond) is done through a vein in the arm. This method is very useful because it allows you to examine all organs at a distance, which makes it possible to identify possible foci of the disease; it also allows you to look for neoplasms if there are metastases in the lymph nodes of the neck, where the primary tumor is not detected.
Ultrasound: it can be useful for examining lymph nodes in the neck. It is a simple, harmless, and quick study. Its limitations are that it is not always possible to accurately distinguish between reactive hypertrophy (i.e., simple inflammation) and tumor invasion of the lymph node.
Biopsy: This involves taking a small piece of “suspicious” tissue, which is sent to a laboratory for analysis under a microscope; it is a diagnostic procedure necessary for the diagnosis of cancer, as well as clarification of the histology of the disease.
Endoscopy under anesthesia: if the disease is not easy to investigate or the patient for various reasons is not able to undergo endoscopic manipulations, then the biopsy material should be taken while the patient is asleep. In this way, the spread of the disease can also be accurately assessed and, possibly, the presence of a second tumor can be detected. The examination under general anesthesia allows a very complete and accurate assessment of the entire upper aero-digestive tract, including the esophagus and trachea, without question.
Needle aspiration: this refers to the extraction of tissue with a fine needle. The needle is guided under ultrasound guidance. After the presence of a tumor is diagnosed and its nature is established, the patient undergoes further examinations to determine the degree of the disease; all of these examinations are called staging. In addition to the above studies, radiation therapy and nuclear medicine are providing valuable information through imaging using rapidly advancing technologies.
How is it treated?
Surgery is the most powerful and widely used weapon in the treatment of these tumors; it includes both resection of the affected area and removal of lymph nodes in the area affected by the tumor. The tumor can be attacked with traditional surgery, endoscopic surgery, modern microsurgery, and various types of laser surgery. Undoubtedly, the surgical laser (we have both CO2 lasers and diode lasers in our institute) today is a very effective tool for endoscopic interventions and open surgeries. Although often complex surgical interventions are involved, modern technologies allow in almost all cases to preserve the basic functions (voice, swallowing) and the aesthetic appearance of the patient without the need to resort to tracheotomy, which leads to serious irreversible disability, or other serious injuries of the past. In special cases requiring extensive surgical destruction, the intervention is completed with reconstructive surgery, almost always carried out during the same operating session thanks to two teams of surgeons.
It involves the use of pedunculated flaps or free revascularized flaps, i.e. sections of skin, muscle, or bone taken from a patient and displaced to replace lost tissue. This provides today tremendous opportunities for the restoration of functional and aesthetic components. For surgical destruction, in which it is necessary to sacrifice nerve structures, in some cases, for example, with extended parotidectomy without preserving the facial nerve (the nerve that drives the muscles of the face), the surgery involves taking another nerve, usually the gastrocnemius, in order to reconstruct the facial nerve during the same operating session.
Radiation therapy and chemotherapy, for which the appropriate specialists are responsible, are other main tools (sometimes of equal or higher effectiveness) in the treatment of this disease. The use of different forms of treatment, either alone or in certain combinations (surgery plus adjuvant radiation therapy; surgery plus adjuvant radiochemotherapy; radiochemotherapy with radical intentions or exclusive radiation therapy, etc.) is a distinguishing feature of the so-called treatment protocols. Compliance with protocol is always assessed at multidisciplinary meetings (multidisciplinary panels) for each patient.