Causes and risk factors
As mentioned above, risk factors are represented by prolonged consumption of alcohol and/or tobacco smoking, as well as other adverse factors such as poor oral hygiene, improper placement of dentures causing mucosal trauma and ulceration, and inhalation of dust and toxic substances.
Human papillomavirus infections (HPV 16-18) are a risk factor for some oropharyngeal cancers, particularly palatine tonsil and base of tongue carcinoma. To date detection of a virus integrated into the tumour cell represents an independent prognostic factor associated with a better prognosis, but does not influence treatment choices outside clinical trials.
Which are the symptoms?
Symptoms of head and neck tumours depend on anatomical disease location. In many cases, however, these tumours develop minor and trivial symptoms. The following symptoms can indicate the diagnosis:
· painful ulcerations in oral cavity not responding to conventional medical treatment;
· lowered tone of voice (dysphonia)
· difficulty swallowing (dysphagia)
· persistent (often painless) neck swelling
· small but persistent oral or nasal bleeding.
Infiltrative forms often feature pain that can be felt in adjacent organs (e.g. the ear).
Dysphonia is characteristic of vocal cord tumours, while difficulty swallowing solid food occurs in vegetative forms of lesions of the first digestive tract. Tumours in the nasal passages and paranasal sinuses can cause breathing difficulties, small or persistent nasal bleeding.
Nasopharyngeal tumours cause changes in vocal timbre if they vegetate, muffled hearing, and early swelling of the cervical lymph nodes.
How is it diagnosed?
It is important to manage oral and neck ulcerations or swelling. Early diagnosis is therefore essential. In early detected neoplasms without lymph node involvement the cure rate is between 75 and 100% of cases. For this purpose, our institute has state-of-the-art multimodal equipment at its disposal:
· rigid (Figure 6) and flexible fibre optic video endoscopic systems able to integrate with NBI (narrow band imaging) light, which is particularly useful to detect altered mucosal vascularisation patterns
· video recording, archiving and image processing systems, videostroboscopy (Figure 8)
In case of late-stage (stage III-IV) diagnosis, the prognosis worsens dramatically: 5-year survival rate is about 40%. Unfortunately, most cases of head and neck cancer are diagnosed at a late stage.
The diagnosis of head and neck cancer is based on clinical and instrumental examinations, which may or may not confirm the suspected disease. If the above symptoms or signs are present, the family doctor will refer the patient for a thorough examination by a specialist and possibly identify the tests that need to be carried out to make a diagnosis.
The most common diagnostic and staging procedures are:
- - Clinical examination: it can be performed by oral cavity examination or, in the case of structures inaccessible to the naked eye, by means of an optical fiberscope. Examination with a fibroscope is an endoscopic technique (meaning 'endospect') because it involves using a flexible tube with its own illumination at the end, which is inserted into nasal passages, allowing the entire otorhinolaryngological area to be examined that cannot be assessed from outside (Figure 9). It is particularly useful to examine the pharynx, larynx and paranasal sinuses. In many patients fiberscope allows direct biopsy. The clinical examination should also include palpation of the suspected lesion to assess the degree of disease infiltration. Finally, a thorough examination of the lymph nodes by palpation of the neck is necessary to assess the possible spread of the disease to the lymph nodes.
- - Radiology is the key of diagnosis with examinations such as ultrasound, computed axial tomography (CT), nuclear magnetic resonance (NMR), positron emission tomography (PET) and CT-PET. These examinations are required for accurate disease staging, therapeutic orientation and subsequent evaluation of the results.
CT (computed tomography) or MRI (magnetic resonance imaging) scan, both with contrast media, are key procedures because they can assess the extent of the disease by providing detailed information on the infiltration in the depth and lymph nodes of the neck.
Chest X-ray is required to rule out lung metastases or co-existing lung tumour; also useful for pre-operative evaluation of the patient.
PET (positron emission tomography): radionuclide (a sugary radioactive liquid causing avid reaction of tumour cells) is injected through an arm vein. This method is very useful because it allows you to examine all the organs at a distance, making it possible to detect any foci of disease; it also allows you to look for neoplasia when there are metastases to lymph nodes in the neck where the primary tumour is undetectable.
Ultrasound can be useful for examining lymph nodes in the neck. It is a simple, harmless and quick examination. Its limitations are that it is not always possible to accurately distinguish between reactive hypertrophy (i.e. simple inflammation) and tumour invasion of the lymph node.
Biopsy: consists of taking a small fragment of "suspicious" tissue, which will be sent to a laboratory for analysis under a microscope; this is a necessary diagnostic procedure to diagnose the tumour as well as to clarify the disease histology.
Endoscopy under anaesthesia: if the disease cannot be easily examined, or if the patient cannot perform endoscopic manoeuvres for various reasons, the biopsy should be performed with the patient asleep. This allows you to accurately assess the disease grade and detect a second tumour. Examination under general anaesthesia certainly allows a complete and accurate assessment of the entire upper aerodigestive tract, including the oesophagus and trachea.
Needle aspiration: this is taking a tissue sample using a fine needle. The needle is guided by ultrasound.
Once a tumour has been diagnosed and its nature established, the patient undergoes further tests to determine the disease grade; all of these tests are called "staging". In addition to the aforementioned tests, radiology and nuclear medicine provide valuable imaging information using rapidly developing technology. Classification
Head and neck cancers are traditionally classified according to the site and volume of the primary lesion (T), the number and size of metastases to lymph nodes in the neck (N) and the presence of distant metastases (M).
How is it treated?
Surgery is the most reliable and widely used tool in treatment of these tumours; it includes both resection of the affected area and removal of lymph nodes in the affected area. The tumour can be managed by traditional surgery, endoscopic surgery, modern microsurgery and the use of different types of laser. Surgical laser (our institute has both CO2 and diode lasers) is certainly a very effective tool for endoscopic and open surgery. Although these surgical procedures are often complex, modern technology makes it possible to preserve the patient's basic functions (voice, swallowing) and aesthetic appearance in almost all cases, without tracheotomy or other prior serious mutilations causing serious irreversible disability. In special cases requiring extensive surgical destruction, surgery is completed by reconstructive surgery, almost always performed in the same operating session by a double surgical team.
It involves the use of pedicled or revascularised free flaps, i.e. sections of skin, muscle or bone tissue taken from the patient and moved to make up for the loss of substance. Today, this offers tremendous opportunities for restoring functional and aesthetic components. In surgical destruction with sacrifice of nerve structures, in some cases, such as extended parotidectomy with sacrifice of the facial nerve (the nerve that moves the facial muscles), the operation includes removal of another nerve, usually the calf nerve, in order to reconstruct the facial nerve itself, in the same surgical session.
Radiotherapy and chemotherapy performed by dedicated specialists are the other main tools (sometimes equally or more effective) to treat the disease. Application of various therapeutic options used alone or in certain combinations (surgery plus adjuvant radiotherapy; surgery plus adjuvant radiochemotherapy; radical radiotherapy or radiotherapy alone; etc.) is characterised by so-called treatment protocols. Adherence to the protocol is always assessed in multidisciplinary meetings (so-called multidisciplinary team meetings) for each patient.