Head and Neck Tumor

Head and neck tumors encompass a wide range of malignant tumors that can occur in or around the throat, mouth, nose, and sinuses. Head and neck tumor is a term used to describe a group of tumors that arise mostly from the upper aerodigestive tracts' surface layers (UADT). Mouth, larynx, pharynx, and nasopharynx make up the upper aerodigestive tract. Because of the involvement of UADT mucus linings, squamous cell carcinomas account for about 90% of all head and neck cancers. Squamous cell carcinoma is a malignant squamous epithelial tumor with significant differentiation and a tendency for primitive and widespread lymph node metastases. Different types of salivary gland tumors can start in head and neck; however, this type of head and neck cancer is quite uncommon. Head and neck tumors are divided into five separate cancer groupings, according to an AIHW analysis from 2014. This classification is based on the location where these tumors start.

Five types of head and neck cancer are classified into 18 separate cancer sites by the International Classification of Diseases (ICD-10). Cancer of indeterminate locations (in the lip, oral cavity, and pharynx) is sometimes classified as part of the 6th group of head and neck cancers. As a result, it is possible for a patient to have many types of tumors in different areas of the head and neck at the same time.

Types of Head and Neck Cancers

Every year, over 64,000 people in the United States suffer head and neck tumor. Squamous cell (epidermoid) carcinoma accounts for more than 90% of head and neck tumors, with adenocarcinomas, sarcomas, and lymphomas accounting for the rest.

The most common locations for head and neck cancer are the mouth and throat.

The larynx (including the supraglottis, glottis, and subglottis)
Oral cavity (tongue, floor of mouth, hard palate, buccal mucosa, and alveolar ridges)
Oropharyngeal space (posterior and lateral pharyngeal walls, base of tongue, tonsils, and soft palate)
Nasopharynx, nasal cavity, and paranasal sinuses, hypopharynx, and salivary glands are all parts of the nasopharynx.

Tumors of the head and neck can also occur in other parts of the body:

Intracranial tumors in adults and children
Orbital and retinal tumors
Acoustic neuromas
Tumors of the skin

Head and Neck Cancer Statistics

In the United States, head and neck tumors account for roughly 5% of all malignancies.

Head and neck tumor is more common as people get older. Although the majority of patients are between the ages of 50 and 70, the incidence of cancers (mainly oropharyngeal) caused by human papillomavirus (HPV) infection is growing in younger people. Men are more likely than women to get head and neck cancer, owing to the fact that male smokers tend to outnumber female smokers and because oral HPV infection is more prevalent in men.

In 2021, more than 69,000 men and women in the United States are expected to be diagnosed with head and neck tumors, according to researchers. The majority of people will be diagnosed with cancer of the mouth, throat, or voice box. Cancers of the paranasal sinuses and nasal cavity, as well as cancers of the salivary glands, are far less frequent.

Head and Neck Tumor Causes

The two most major risk factors for head and neck cancers, particularly tumors of the oral cavity, hypopharynx, and voice box, are alcohol and tobacco use (including smoke exposure and smokeless tobacco, sometimes known as "chewing tobacco" or "snuff"). People who use both nicotine and alcohol are more likely to get these cancers than people who just use one of the two. Tobacco and alcohol use are the leading causes of squamous cell carcinomas of the mouth and larynx in the head and neck.

Infection with cancer-causing strains of the human papillomavirus (HPV), particularly HPV type 16, is linked to oropharyngeal malignancies of the tonsils and base of the tongue. The proportion of oropharyngeal cancers induced by HPV infection is growing in the United States, whereas the incidence of oropharyngeal cancers due by other causes is decreasing. Chronic HPV infection is responsible for almost three-quarters of all oropharyngeal tumors. Although HPV can be found in other head and neck tumors, it appears to be the sole cause of oropharyngeal cancer. The causes for this remain unknown.

The following are some of the other recognized risk factors for head and neck cancers:

Paan (betel quid). The consumption of paan (betel quid) in the mouth, which is a common practice in Southeast Asia, has been linked to a higher risk of mouth cancer.
Occupational exposure. Nasopharyngeal tumor is linked to occupational exposure to wood dust. Certain occupational exposures, such as asbestos and synthetic fibers, have been linked to laryngeal cancer, but the evidence for this correlation is still inconclusive. Certain occupations in the building, metal, textile, ceramic, logging, and food companies may raise the risk of voice box tumor. Wood dust, nickel dust, and formaldehyde exposure in the workplace are all linked to malignancies of the paranasal sinuses and nasal cavity.
Exposure to radiation. Radiation to the head and neck, whether for noncancerous or cancerous diseases, increases the chance of salivary gland tumors.
Infection with Epstein-Barr virus. Nasopharyngeal tumor and tumors of the salivary glands are linked to Epstein-Barr virus infection.
Ethnicity. Nasopharyngeal tumor is linked to Asian ancestry, especially Chinese roots.
Underlying genetic disorders. Some genetic diseases, such as Fanconi anemia, raise the chance of premalignant lesions and malignancies forming early in life.

Head and Neck Tumor Symptoms

A lump in the neck, a sore in the mouth or throat that does not heal and is bothersome, a persistent sore throat, difficulty swallowing, and a change or hoarseness in the voice are all possible symptoms of head and neck tumor. Other, less dangerous diseases can also cause these symptoms. Any of these symptoms should be checked out by a doctor or dentist.

tumors in certain parts of the head and neck can cause the following symptoms:

Oral cavity. Abnormal bleeding or pain; a white or red patches on the gums, tongue, or mouth lining; a growth or swelling of the jaw that causes dentures to fit improperly or become irritating.
The Throat (pharynx). Pain when swallowing; persistent pain in the neck or throat; pain or ringing in the ears; or difficult hearing.
Voice box (larynx). Respiratory or speaking difficulties, swallowing discomfort, or earache are all possible symptoms.
Nasal cavity and paranasal sinuses. Blockages in the sinuses that do not resolve; chronic sinus infections that do not resolve with antibiotic therapy; bleeding through the nose; persistent headaches, swelling, or other eye issues; pain in the upper teeth; or denture issues.
Salivary glands. Swelling beneath the chin or around the mandible, numbness or paralysis of the facial muscles, or persistent pain in the face, chin, or neck.

Head and Neck Tumor Diagnosis

Clinical evaluation
Biopsy
Imaging studies and endoscopy used to determine the extent of the tumor

The best method to discover tumors early, before they become symptomatic, is to have a routine physical examination (which includes a complete oral examination). Brush biopsy kits are commercially available and can be used to screen for oral tumors. Any sore throat, hoarseness, or otalgia that lasts longer than two to three weeks should be sent to a head and neck professional, who will most likely do a flexible fiberoptic laryngoscopy to assess the larynx and pharynx.

A biopsy is usually required for a definitive diagnosis. A neck mass is biopsied using fine-needle aspiration, which is well tolerated, accurate, and, apart from an open biopsy, has no impact on future possible treatments. An incisional biopsy or a brush biopsy are used to assess oral lesions. Endoscopic biopsies of nasopharyngeal, oropharyngeal, or laryngeal lesions are performed.

Imaging studies such as CT scan, MRI, or PET scan are used to identify the size of the main tumor, whether it has spread to surrounding structures, and whether it has spread to the lymph nodes in the neck.

Head and Neck Tumor Staging

The size and location of the primary tumor (T), the number and size of metastases to the cervical lymph nodes (N), and evidence of distant metastases (M) are used to stage head and neck tumors. The HPV status is also taken into account when it comes to oropharyngeal cancer. Imaging with CT, MRI, or both, as well as PET scan, is frequently required for staging.

The findings of the physical examination and tests performed before to surgery are used to determine clinical staging (cTNM). Pathologic staging (pTNM) is determined by the pathologic features of the original tumor and the number of positive nodes discovered during surgery.

Extranodal extension is included in the "N" category for tumor that has spread to the neck nodes. Extranodal extension is diagnosed clinically when there is evidence of gross extranodal extension during a medical evaluation, as well as imaging tests that confirm the observation. Histologic evidence of tumor in a lymph node extending through the lymph node capsule into the surrounding fibrous tissue, with or without concomitant stromal reactivity, is referred to as pathologic extranodal extension.

Treatment for Head and Neck Cancers

Surgery and radiation are the most common treatments for head and neck tumor. These treatments can be used alone or in conjunction with chemotherapy, and they can be used with or without chemotherapy. Many tumors behave identically with surgery and radiation therapy regardless of site, allowing other factors such as patient preference or location-specific morbidity to influence therapy selection.

However, at specific sites, one modality clearly outperforms the others. For example, surgery is preferable to radiotherapy for early-stage oral tumor because radiation therapy causes mandibular osteoradionecrosis. Endoscopic surgery is becoming more popular; in certain head and neck tumors, it has cure rates that are comparable to or better than open surgery or radiation, and it has much less morbidity. Endoscopic techniques are most commonly utilized for laryngeal surgery, and the cuts are usually made with a laser. Endoscopic techniques are also being employed to treat certain sinonasal tumors.

If radiotherapy is chosen as the primary treatment, it is given to the primary location as well as the cervical lymph nodes on both sides. The main site, histologic criteria, and risk of nodal disease all influence whether lymphatics are treated with radiotherapy or surgery. Early-stage tumors rarely necessitate lymph node treatment, whereas more advanced tumors do. Sites with a lot of lymphatics (like the oropharynx and supraglottis) frequently need lymph node radiotherapy regardless of tumor stage, whereas sites with a little lymphatics (like the larynx) usually don't (for early-stage). Intensity-modulated radiation therapy (IMRT) targets a small area of the body with radiation, potentially minimizing side effects while maintaining tumor control.

Advanced-stage tumor (stages III and IV) frequently need a multimodal approach that includes a combination of chemotherapy, radiotherapy, and surgery. Bone or cartilage invasion necessitates surgical removal of the main site and, in most cases, regional lymph nodes (because of the high potential of nodal metastasis). If the primary site is surgically treated, high-risk characteristics such as numerous lymph nodes with malignancy or extracapsular spread are treated with postoperative radiotherapy to the cervical lymph nodes. Because irradiated tissues heal poorly, postoperative radiation is usually preferable than preoperative radiation.

Recent research has found that combination of chemotherapy with adjuvant neck radiotherapy enhances regional tumor control and survival. However, because this technique has serious side effects, such as exacerbated dysphagia and bone marrow suppression, it is important to think carefully about whether or not to add chemotherapy.

Combined chemotherapy and radiotherapy are frequently used to treat advanced squamous cell carcinoma without bone involvement. Combining chemotherapy and radiotherapy, despite being presented as organ-sparing, doubles the likelihood of acute toxicities, including significant dysphagia. For debilitated patients with severe disease who cannot withstand the side effects of chemotherapy and are too risky for general anesthesia, radiation may be administered alone.

Chemotherapy is rarely utilized as a first-line treatment for cancer. Primary chemotherapy is only used for chemosensitive tumors like Burkitt lymphoma or individuals with extensive metastases (e.g., hepatic or pulmonary involvement). Cisplatin, fluorouracil, and methotrexate are among of the medications used to relieve pain and shrink tumors in patients who are unable to be treated with conventional treatments. The response may be favorable at first, but it is not long-lasting, and the tumor almost always reappears. For some patients, targeted medications like cetuximab are increasingly being utilized instead of standard chemotherapy treatments, however efficacy data is insufficient.

Because head and neck tumor treatments are so complicated, interdisciplinary treatment planning is required. Each patient should be reviewed by a tumor board made up of representatives from all treating professions, as well as radiologists and pathologists, in order to achieve a consensus on the best treatment option. A team of ear, nose, and throat and reconstructive surgeons, radiation and medical oncologists, speech and language pathologists, dentists, and nutritionists is most suited to arrange treatment once it has been determined.

Because the use of free-tissue transfer flaps has enabled functional and cosmetic reconstruction of deformities to significantly improve a patient's quality of life after procedures that previously caused excessive morbidity, plastic and reconstructive surgeons are playing an increasingly important role. The fibula (typically utilized to reconstruct the jaw), the radial forearm (frequently used for the tongue and floor of mouth), and the anterior lateral thigh are also common donor locations (often used for laryngeal or pharyngeal reconstruction).

Head and Neck Tumor Recurrence Treatment

Managing recurring tumors after treatment is difficult and associated with risks. After treatment, a palpable mass or ulcerated lesion at the initial location with edema or pain strongly indicates a persistent tumor. CT (with thin slices) or MRI are required for such patients.

All scar planes and reconstructive flaps, as well as any remaining tumor, are removed in the case of local recurrence following surgical intervention. Radiotherapy, chemotherapy, or a combination of the two may be used, but their effectiveness is limited. Surgery is the best treatment for patients who have a recurrence after radiotherapy. Additional radiation treatments may benefit some patients, but this strategy carries a significant risk of side effects and should be used with caution. Pembrolizumab and nivolumab, immune checkpoint inhibitors, are approved for recurrent or metastatic tumors resistant to platinum-based chemotherapy, however, efficacy evidence demonstrating improvement is limited to small trials.

Head and Neck Tumor Treatment Side Effects

Every cancer treatment has the potential for problems and side effects. Because many treatments have comparable cure rates, modality selection is mostly dependent on actual or perceived differences in side effects.

Although surgery is usually regarded to be the cause of the highest morbidity, various treatments can be performed with little or no effect on aesthetics or function. Prostheses, grafts, regional pedicle flaps, and complex free flaps, among other more complex reconstructive surgeries and techniques, can often restore function and appearance to near-normal levels.

Lethargy, significant nausea and vomiting, mucositis, transient hair loss, gastroenteritis, hematological and immunological suppression, and infection are all toxic consequences of chemotherapy.

Radiation therapy for head and neck tumor has a number of side effects. A dose of around 40 Gray permanently destroys the function of any salivary gland within the field, leading in xerostomia, which greatly raises the risk of dental caries. In some cases, newer radiation treatments like intensity-modulated radiation therapy (IMRT) can reduce or eliminate hazardous doses to the parotid glands.

Furthermore, dosages of > 60 Gray impair the blood flow of bone, especially in the jaw, and osteoradionecrosis may result. Tooth extraction sites degenerate in this condition, sloughing bone and soft tissue. As a result, all necessary dental work, such as scaling, fillings, and extractions, should be completed before radiotherapy. Any teeth that are in bad shape and can't be saved should be extracted.

Oral mucositis and dermatitis in the overlying skin are also possible side effects of radiotherapy, which might lead to dermal fibrosis. Taste loss and decreased smell sensation are common but typically only temporary.

Head and Neck Tumor Prognosis

The tumor size, initial location, origin, and presence of regional or distant metastases all influence the prognosis of head and neck cancer. In general, if a tumor is detected early and treated promptly and appropriately, the prognosis is excellent.

Head and neck tumors invade the local area initially, then spread to the surrounding cervical lymph nodes. The spread of tumor to the regional lymphatics is linked to tumor size, extent, and aggressiveness, and it decreases overall survival by half. Patients with advanced-stage tumor are more likely to develop distant metastases (most commonly to the lungs). Distant metastases have a significant impact on survival and are virtually invariably incurable.

The cure rate is also dramatically reduced in advanced local diseases (a criteria for advanced T stage) with invasion of muscle, bone, or cartilage. Perineural spread, as indicated by pain, paralysis, or numbness, suggests a very aggressive tumor, is linked to nodal metastasis, and has a poor prognosis when compared to a similar lesion that does not have perineural invasion.

5-year survival rates for stage I tumors can be as high as 90 percent, 70 to 80 percent for stage II tumors, 50 to 75 percent for stage III tumors, and up to 50 percent for some stage IV tumors with adequate therapy. Depending on the primary location and cause, the survival rates vary substantially. When compared to other tumors, stage I laryngeal carcinoma has a high survival rate. When compared to oropharyngeal cancers caused by cigarettes or alcohol, HPV-related oropharyngeal cancers have a much better prognosis. Because the prognosis of HPV-positive and HPV-negative oropharyngeal malignancies differs, all oropharyngeal tumors should be screened for HPV regularly.

Head and Neck Tumor Prevention

People who are at risk for head and neck tumors, especially those who smoke, should speak with their doctor about options to quit smoking and lower their risk.

HPV-related head and neck tumors can be reduced by avoiding oral HPV infection. The Food and Drug Administration gave the HPV vaccine Gardasil 9 rapid approval in June 2020 for the prevention of oropharyngeal and other head and neck tumors caused by HPV strains 16, 18, and 58 in people aged 10 to 45.

Although there is no standardized or routine screening test for head and neck tumors, dentists can look for hallmarks of cancer in the oral cavity during a routine checkup.

Conclusion

Despite the fact that head and neck tumor is linked to pain, disfigurement, dysfunction, emotional suffering, and death, recent developments have resulted in significant improvements in outcomes. Immune checkpoint inhibitors were introduced for the treatment of recurrent or advanced head and neck tumors, and some patients saw a significant improvement. Improvements in standard therapy, such as minimally invasive, organ-sparing surgical procedures, breakthroughs in radiation, and curative multimodal therapies, have improved function while lowering morbidity and mortality. Increased awareness and detection of human papillomavirus (HPV)–associated oropharyngeal cancer, as well as reductions in tobacco-related head and neck malignancies, are transforming the understanding of the disease, its management, and the prognosis for those who are affected.