Head & Neck Cancer

Risk factors

Pathology

Spread

Diagnosis

Staging

Therapy

            Surgical resection

            Radiation therapy

            Chemotherapy

            Combined chemo-radiation 

References and selected reading

Head & Neck Cancer

Head & Neck (H&N) cancer represents about 3-6 % of the newly diagnosed cancers. Each year more than 650000 new patients are diagnosed world-wide. This disease is more prevalent among men than women (2:1 ratio).

Risk factors

Risk factors are mainly Smoking and Alcohol consumption; when combined, the risk markedly increases. Higher incidence of H&N cancer was also observed after radiation exposure (Chernobyl). Ultra violet light is correlated with some of H&N cancers (lip cancer).  

Pathology 

Squamous Cell Carcinoma is the most prevalent entity and occurs in more than 90% of cases.

Spread 

The most important parameter for treatment of H&N cancer is the stage of the disease. Localized disease without lymph nodes involvement or distant spread yields the most favorable prognosis. Distant spread occurs most commonly to lungs.

Diagnosis 

 Several steps should be performed for diagnosis of H&N cancer:

1. Careful history taking from the patient by an experienced physician. Patients may be asymptomatic, but complaints such as difficulty in swallowing (dysphagia), painful swallowing (odynophagia), nasal obstruction or bleeding (epistaxis), hearing impairment and changes in the patient’s voice may be elicited. These symptoms can direct the clinician to the problem site.
2. Careful physical examination, including ear, nose and throat inspection. Special attention should be given to discover and document any enlarged lymph nodes. Neurological examination including cranial nerves testing should be performed.
3. Laboratory tests. These tests should include a complete blood cell count, serum electrolytes (including calcium), and liver and kidney function tests.
4. Radiological evaluation should include contrast enhanced computerized tomography of the head and neck, chest radiograph/ chest computerized tomography. Magnetic resonance imaging should be spared to selected patients; bone scan should be performed if there is clinical or laboratory suspicion of bone metastasis (increased calcium levels, bone pain…) or if lymph nodes enlargement exist; positron emission tomography should be considered for detection of metastatic disease. The decision regarding the diagnostic modalities should be determined according to the clinical judgment of the treating oncologist.
5. Tissue biopsy should be obtained in order to make the final diagnosis. Biopsies are usually obtained from the most easily approached disease site.

Staging  

The most used staging system is that of the American Joint Committee on Cancer (cancer staging manual 6^th edition, NY, Springer –Verlag, 2002).

Therapy

The decision regarding the treatment of H&N cancer should be tailored to every patient, and should be designed by a multidisciplinary team of physicians that includes surgeons, ENT specialists, radiation oncologist and clinical oncologist. The treatment modalities are:

Surgical resection. Surgical resection is considered in patients with H&N cancer who suffer from squamous cell carcinoma and localized disease.

Radiation therapy. Play a pivotal role in the treatment of patients with H&N cancer. Mostly, 6-7 weeks (5 days/week) of radiation therapy (2 Gy/d; 60-70 Gy/course) is administered. Several groups suggest applying radiation therapy twice/ three times daily and thus shortening the time of treatment and probably increasing its efficiency; these regimens are currently experimental.

Chemotherapy. Chemotherapy is given to locally advanced or metastatic disease. Combination chemotherapy is superior to single agent treatment. One drug should be platinum based (cisplatin or carboplatin). Neoadjuvant chemotherapy (administered before performing surgical resection) resulted in more successful organ preservation (e.g. laryngeal cancer).

Combined chemo-radiation. Radiation may be combined with intravenous weekly cisplatin, or with weekly carboplatin and paclitaxel. The later combination is used if a contraindication to cisplatin exists (hearing loss, neuropathy, kidney disease…). Chemo-radiation is used for curative intent, as primary or adjuvant (after performing surgical resection) treatment, and give superior results than treatment with chemotherapy alone. Adjuvant Chemo-radiation is recommended for locally advanced head and neck cancer.

References and selected reading.

1. Specenier PM, Vermorken JB. Neoadjuvant chemotherapy in head and neck cancer: Should it be revisited? Cancer Lett. 2007; 256(2):166-77. Read This Article

2. Bernier J. Head and neck oncology: what the past decade has taught us.
   Expert Rev Anticancer Ther. 2006; 6(9):1133-6. Read This Article

3. Bernier J, Domenge C, Ozsahin M, Matuszewska K, Lefebvre JL, Greiner RH, Giralt J, Maingon P, Rolland F, Bolla M, Cognetti F, Bourhis J, Kirkpatrick A, van Glabbeke M; European Organization for Research and Treatment of Cancer Trial 22931. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med. 2004; 350(19):1945-52. Read This Article

4. Huguenin P, Beer KT, Allal A, Rufibach K, Friedli C, Davis JB, Pestalozzi B, Schmid S, Thoni A, Ozsahin M, Bernier J, Topfer M, Kann R, Meier UR, Thum P, Bieri S, Notter M, Lombriser N, Glanzmann C. Concomitant cisplatin significantly improves locoregional control in advanced head and neck cancers treated with hyperfractionated radiotherapy. J Clin Oncol. 2004; 22(23):4665-73. Read This Article

5. Cooper JS, Pajak TF, Forastiere AA, Jacobs J, Campbell BH, Saxman SB, Kish JA, Kim HE, Cmelak AJ, Rotman M, Machtay M, Ensley JF, Chao KS, Schultz CJ, Lee N, Fu KK; Radiation Therapy Oncology Group 9501/Intergroup. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med. 2004; 350(19):1937-44. Read This Article

6. Juweid ME, Cheson BD. Positron-emission tomography and assessment of cancer therapy. N Engl J Med. 2006; 354(5):496-507. Read This Article

7. Buck G, Huguenin P, Stoeckli SJ. Efficacy of neck treatment in patients with head and neck squamous cell carcinoma. Head Neck. 2007; DOI 10.1002/hed.20657. Read This Article

8. Agarwala S, Cano E, Heron D, Johnson J, Myers E, Sandulache V, Bahri S, Ferris R, Wang Y, Argiris A. Long-term outcomes with concurrent carboplatin, paclitaxel and radiation therapy for locally advanced, inoperable head and neck cancer. Ann Oncol. 2007; 18(7):1224-1229. Read This Article

9. Hitt R, Lopez-Pousa A, Martinez-Trufero J, Escrig V, Carles J, Rizo A, Isla D, Vega ME, Marti JL, Lobo F, Pastor P, Valenti V, Belon J, Sanchez MA, Chaib C, Pallares C, Anton A, Cervantes A, Paz-Ares L, Cortes-Funes H. Phase III study comparing cisplatin plus fluorouracil to paclitaxel, cisplatin, and fluorouracil induction chemotherapy followed by chemoradiotherapy in locally advanced head and neck cancer.J Clin Oncol. 2005; 23(34):8636-45. Read This Article

10. Adelstein DJ, Leblanc M. Does induction chemotherapy have a role in the management of locoregionally advanced squamous cell head and neck cancer? J Clin Oncol. 2006; 24(17):2624-8. Read This Article

11. Zorat PL, Paccagnella A, Cavaniglia G, Loreggian L, Gava A, Mione CA, Boldrin F, Marchiori C, Lunghi F, Fede A, Bordin A, Da Mosto MC, Sileni VC, Orlando A, Jirillo A, Tomio L, Pappagallo GL, Ghi MG. Randomized phase III trial of neoadjuvant chemotherapy in head and neck cancer: 10-year follow-up. J Natl Cancer Inst. 2004; 96(22):1714-7. Read This Article