Presentation :
- Risk factors:
- The most important risk factor for head and neck cancer is smoked and smokeless tobacco use.
- Alcohol use is also a known risk factor, and the combination of alcohol and tobacco synergistically increases the risk.
- HPV infection, particularly causing carcinoma of tonsils and tongue base
- malignant neck masses are commonly painless, firm, and/or fixed on examination and not associated with antecedent infection
Pathophysiology :
Diagnostics :
- Fine-needle aspiration of suspicious neck masses is accurate for diagnosis of squamous cell carcinoma.
- p16 is overexpressed in HPV-positive cancers. Tumor staining for p16 is standard for oropharyngeal cancers.
- Imaging:
- MRI is preferred for assessment of the primary tumor.
- PET/CT is useful to evaluate regional nodes and rule out distant metastatic disease, although it is not accurate in nodes 5 mm or smaller.
Treatment :
- Approximately one third of patients who present with small tumors without lymph node metastases are effectively treated with either surgery or radiation therapy.
- Radiation therapy and larynx-sparing surgery, consisting of either transoral laser surgery or open partial laryngectomy, offer equivalent survival benefit in patients with early-stage laryngeal cancer.
- Adjuvant irradiation for patients with primary surgical resection is recommended for those with one or more high-risk pathology features:
- T3 or T4 tumor, Positive resection margins, Lymph node extracapsular extension, ≥2 positive lymph nodes (N2 or N3), Perineural invasion, Lymphovascular invasion
- For patients with an unresectable primary tumor or extensive nodal disease, initial treatment with combined chemotherapy, either cisplatin or cetuximab, and irradiation is recommended.
- For distant metastatic disease or unresectable persistent local disease (not amenable to surgery or irradiation):
- a combination of platinum-based chemotherapy and pembrolizumab
- or in patients with programmed death ligand 1–positive cancer, use of pembrolizumab alone.
- Post-treatment monitoring:
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- Routine imaging for head and neck cancer after a negative posttreatment scan is not indicated unless signs and symptoms suggest recurrent disease.
- Although patients who receive radiation therapy that includes the thyroid bed are at increased risk of thyroid cancer, screening thyroid ultrasonography is not indicated.
Prognosis:
- The prognosis of HPV-associated oropharynx cancer in nonsmokers is significantly better than that for non–HPV-related cancer.
- . HPV-related cancer of the oropharynx has a different staging system than non–HPV-related cancer based on significant differences in prognosis
- Patients with early-stage head and neck cancers have 70% to 90% long-term survival
- Up to 20% of head and neck cancer survivors develop a second primary cancer related to smoking and alcohol exposure