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 Cancer Head and Neck Care Treatment Diagnosis 

Chemotherapy Chemo Radiation Cure.

 

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Welcome,
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<
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 Thyroid
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Larynx
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  Small Intestine
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You can find this site again  by typing in the  Google search engine  the unique word " 1noitaidaR "  which is  OR " Radiation1 " backwards.

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 Brian Nelson, Webpage Marketing Consultant 
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Misspelled words used to find this page 1 of 3. BB
 Most Common Cancers

 Breast
 Prostate
 Lung and Bronchus
 Colon and Rectum
 Urinary Bladder
  Non-Hodgkin Lymphoma
 Melanomas of the Skin
 Kidney and Renal Pelvis
 Pancreas
 Oral Cavity and Pharynx (Head & Neck)
 Ovary
<
Less Common Cancers
 Thyroid
 Stomach
 Brain
 Multiple Myeloma
 Esophagus
 Liver and Intrahepatic Bile Duct
 Cervix

Larynx
 Acute Myeloid Leukemia
 Chronic Lymphocytic Leukemia
 Soft Tissue including Heart
 Hodgkin Lymphoma
 Testis
 

  Small Intestine
 Chronic Myeloid Leukemia
 Acute Lymphocytic Leukemia
 Anus, Anal Canal and Anorectum
 Vulva
 Gallbladder
 Pleura, Malignant Mesothelioma
 Bones and Joints
 Hypopharynx
 Eye and Orbit
 Nose, Nasal Cavity and Middle Ear
 Nasopharynx
 Ureter
 Peritoneum, Omentum and Mesentery
 Gastrointestinal Carcinoid Tumors

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 You are at http://www.BrianNelsonConsulting.com/cancer-care-treatment/head-neck-diagnosis1.html  Wednesday, 03. January 2007 09:44 AM -0600

 
Misspelled Words on this pagecancer, censer, cancel, cencel, cansel, censel, cacer, cencer, canser, caner, canel, cainl, cainr, ceiner, ceinel, cance, cence, canse, cense, canc, cenc, cancre, camcer, canecr, cacner, cnacer, acncer, cancr, cncer, ancer,  radiation, radaitiom, radyatiom, ladiatiom, rdiation, ladaitiom, raiation, ladyatiom, radation, radition, radiaion, radiatin, radiatiom, ladiashon, radyaton, ladaision, ladaishon, radyashun, radaition, ladyasion, ladyation, radyashon, radiaton, ladyaton, ladiation, radaiton, ladyashun, ladaition, radiashun, ladyashon, ladiaton, radaishun, radiasion, ladaiton, radiashon, radaision, ladiashun, radaishon, radyasion, ladaishun, radyation, ladiasion, rad1at1on, radiatino, radiatoin, radiaiton, raditaion, raidation, rdaiation, ardiation, radiatio, adiation\, therapy, thelapie, therepie, tehrepie, terapy, tehlapie, thrapy, thelepie, theapy, tehlepie, therpy, theray, therapie, tehrapie, tehlapi, thelepy, tehlepy, therapi, tehrapy, tehrapi, thelapy, thelapi, therepy, tehrepy, tehlapy, therayp, therpay, thearpy, threapy, hterapy, therap, herapy, chmotherapy, chemotherapy, czemutherapie, czemotehrapi, czemothelepy, chemotehlepie, chemotehrapie, cheotherapy, czemothelepie, chemotehlapi, czemuthelepy, chemuthelepie, chemutherapie, chemtherapy, czemotherepie, chemutehrapi, czemotherepy, czemotherapy, chemothelapie, chemoherapy, czemotehrapie, czemotehlepy, czemutherepy, czemothelapy, chemuthelapie, chemoterapy, chemutehrapie, chemutehlepy, czemotehrapy, czemutherapy, chemotherepie, chemothrapy, czemotehrepy, czemotehlapy, czemuthelapy, chemotehrepie, chemotheapy, chemutehrepy, chemutehrapy, czemotherapi, chemutherepie, chemotherpy, czemotherapie, czemutehrapy, czemothelapi, chemotehlapie, chemotheray, cemotherapy, czemothelapie, chemutehlapy, czemutherapi, chemothelepie, chemotherapie, chemuthelapi, chemotherepy, chemotherapi, chemotehrepy, chemotehrapy, chemutherepy, chemotehrapi, chemotehlapy, chemutherapy, chemothelepy, chemutherapi, chemotehlepy, chemothelapy, chemuthelepy, chemothelapi, chemuthelapy, chenotherapy, chemotherayp, chemotherpay, chemothearpy, chemothreapy, chemohterapy, chemtoherapy, cheomtherapy, chmeotherapy, cehmotherapy, hcemotherapy, chemotherap, hemotherapy> chemothreapy, chemohterapy, chemtoherapy, cheomtherapy, chmeotherapy, cehmotherapy, hcemotherapy, chemotherap, hemotherapy,radiation, radaitiom, radyatiom, ladiatiom, rdiation, ladaitiom, raiation, ladyatiom, radation, radition, radiaion, radiatin, radiatiom, ladiashon, radyaton, ladaision, ladaishon, radyashun, radaition, ladyasion, ladyation, radyashon, radiaton, ladyaton, ladiation, radaiton, ladyashun, ladaition, radiashun, ladyashon, ladiaton, radaishun, radiasion, ladaiton, radiashon, radaision, ladiashun, radaishon, radyasion, ladaishun, radyation, ladiasion, rad1at1on, radiatino, radiatoin, radiaiton, raditaion, raidation, rdaiation, ardiation, radiatio, adiation, cure, cule, crue, clue, cuer, ucre
Head and Neck Cancer

Overview

Head and neck cancer is the term given to a variety of malignant tumors that develop in the

  • oral cavity (mouth);
  • pharynx (throat);
  • paranasal sinuses (small hollow spaces around the nose lined with cells that secrete mucus);
  • nasal cavity (airway just behind the nose);
  • larynx ("Adam's apple" or voice box); and
  • salivary glands (parotid, submanidular, sublingual glands that secrete saliva).

Many authorities also include skin tumors of the face and neck and tumors of the cervical lymph nodes.

Excluding superficial skin cancers, but including cancer of the larynx and thyroid, it is conservatively estimated that about 60,000 people are diagnosed with head and neck cancer annually - about 5% of all cancers diagnosed in the United States. There are more than half a million survivors of oral, head, and neck cancer living in the United States today.

Anatomy of the head and neck
The head and neck can be divided into several different regions:

Pharynx
Click here for image enlargement.
  • nasopharynx: area behind the nose
  • pharynx: hollow tube at the upper part of the throat that starts behind the nose, runs down to the neck, and becomes part of the esophagus, the tube that goes to the stomach
  • oral cavity: lips, floor of mouth, tongue, buccal mucosa (lining inside the lips and cheeks), gingiva (gums) and hard palate (bony top of the mouth), salivary glands (parotid, submandibular and minor salivary glands)
  • oropharynx: base of tongue, tonsillar region, soft palate and pharyngeal walls
  • hypopharynx: bottom part of the throat
  • larynx (voice box): supraglottic, glottic (vocal cords), and subglottic regions
  • nasal cavity: paranasal sinuses (ethmoid and maxillary)

Risk Factors  Factors known to contribute to the risk of developing head and neck cancers include smoking (both tobacco and marijuana) or chewing tobacco and alcohol use. Leukoplakia (white spots or patches in the mouth) also may be considered a risk factor, as this condition becomes cancerous in approximately one-third of patients.

Pathology
Most head and neck cancers are squamous cell carcinomas, tumors that develop in the tissue lining the hollow organs of the body. However, other tumor types also may be seen and include lymphoepithelioma, spindle cell carcinoma, verrucous cancer, undifferentiated carcinoma and cancers of the lymph nodes, called lymphoma (most often diffuse non-Hodgkins lymphoma).

Date reviewed: 03/09/2005
 Head and Neck Cancer: Questions and Answers
Key Points
  • Most head and neck cancers begin in the squamous cells that line the mucosal surfaces in the head and neck. Head and neck cancers are identified by the area in which they begin (see Question 2).
  • Tobacco and alcohol use are the most important risk factors for head and neck cancers. People who are at risk for this disease should talk with their doctor about ways they can reduce their risk and how often to have checkups (see Question 4).
  • Typical symptoms of head and neck cancer include a lump or sore (for example, in the mouth) that does not heal, a sore throat that does not go away, difficulty swallowing, and a change or hoarseness in the voice (see Question 5).
  • The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person’s age and general health (see Question 8).
  • Rehabilitation and regular follow-up care are important parts of treatment for patients with head and neck cancer (see Questions 10 and 11).
  1. What is cancer?

    Cancer is a group of many related diseases that begin in cells, the body’s basic unit of life. Normally, cells grow and divide to form new cells in an orderly way. They perform their functions for a while, and then they die. Sometimes, however, cells do not die. Instead, they continue to divide and create new cells that the body does not need. The extra cells form a mass of tissue, called a growth or tumor. There are two types of tumors: benign and malignant. Benign tumors are not cancer. They do not invade nearby tissue or spread to other parts of the body. Malignant tumors are cancer. Their growth invades normal structures near the tumor and spreads to other parts of the body. Metastasis is the spread of cancer beyond one location in the body.

  2. What kinds of cancers are considered cancers of the head and neck?

    Most head and neck cancers begin in the cells that line the mucosal surfaces in the head and neck area, e.g., mouth, nose, and throat. Mucosal surfaces are moist tissues lining hollow organs and cavities of the body open to the environment. Normal mucosal cells look like scales (squamous) under the microscope, so head and neck cancers are often referred to as squamous cell carcinomas. Some head and neck cancers begin in other types of cells. For example, cancers that begin in glandular cells are called adenocarcinomas.

    Cancers of the head and neck are further identified by the area in which they begin:

    • Oral cavity. The oral cavity includes the lips, the front two-thirds of the tongue, the gingiva (gums), the buccal mucosa (lining inside the cheeks and lips), the floor (bottom) of the mouth under the tongue, the hard palate (bony top of the mouth), and the small area behind the wisdom teeth.

       

    • Salivary glands. The salivary glands produce saliva, the fluid that keeps mucosal surfaces in the mouth and throat moist. There are many salivary glands; the major ones are in the floor of the mouth, and near the jawbone.

       

    • Paranasal sinuses and nasal cavity. The paranasal sinuses are small hollow spaces in the bones of the head surrounding the nose. The nasal cavity is the hollow space inside the nose.

       

    • Pharynx. The pharynx is a hollow tube about 5 inches long that starts behind the nose and leads to the esophagus (the tube that goes to the stomach) and the trachea (the tube that goes to the lungs). The pharynx has three parts:
       

         

      • Nasopharynx. The nasopharynx, the upper part of the pharynx, is behind the nose.

         

      • Oropharynx. The oropharynx is the middle part of the pharynx. The oropharynx includes the soft palate (the back of the mouth), the base of the tongue, and the tonsils.

         

      • Hypopharynx. The hypopharynx is the lower part of the pharynx.

       

    • Larynx. The larynx, also called the voicebox, is a short passageway formed by cartilage just below the pharynx in the neck. The larynx contains the vocal cords. It also has a small piece of tissue, called the epiglottis, which moves to cover the larynx to prevent food from entering the air passages.

       

    • Lymph nodes in the upper part of the neck. Sometimes, squamous cancer cells are found in the lymph nodes of the upper neck when there is no evidence of cancer in other parts of the head and neck. When this happens, the cancer is called metastatic squamous neck cancer with unknown (occult) primary.

    Cancers of the brain, eye, and thyroid as well as those of the scalp, skin, muscles, and bones of the head and neck are not usually grouped with cancers of the head and neck.

  3. How common are head and neck cancers?

    Head and neck cancers account for approximately 3 to 5 percent of all cancers in the United States. These cancers are more common in men and in people over age 50. It is estimated that about 39,000 men and women in this country will develop head and neck cancer in 2005.

  4. What causes head and neck cancers?

    Tobacco (including smokeless tobacco, sometimes called “chewing tobacco” or “snuff”) and alcohol use are the most important risk factors for head and neck cancers, particularly those of the oral cavity, oropharynx, hypopharynx, and larynx. Eighty-five percent of head and neck cancers are linked to tobacco use. People who use both tobacco and alcohol are at greater risk for developing these cancers than people who use either tobacco or alcohol alone.

    Other risk factors for cancers of the head and neck include the following:

    • Oral cavity. Sun exposure (lip); possibly human papillomavirus (HPV) infection.

       

    • Salivary glands. Radiation to the head and neck. This exposure can come from diagnostic x-rays or from radiation therapy for noncancerous conditions or cancer.

       

    • Paranasal sinuses and nasal cavity. Certain industrial exposures, such as wood or nickel dust inhalation. Tobacco and alcohol use may play less of a role in this type of cancer.

       

    • Nasopharynx. Asian, particularly Chinese, ancestry; Epstein-Barr virus infection; occupational exposure to wood dust; and consumption of certain preservatives or salted foods.

       

    • Oropharynx. Poor oral hygiene; HPV infection and the use of mouthwash that has a high alcohol content are possible, but not proven, risk factors.

       

    • Hypopharynx. Plummer-Vinson (also called Paterson-Kelly) syndrome, a rare disorder that results from iron and other nutritional deficiencies. This syndrome is characterized by severe anemia and leads to difficulty swallowing due to webs of tissue that grow across the upper part of the esophagus.

       

    • Larynx. Exposure to airborne particles of asbestos, especially in the workplace.

    Immigrants from Southeast Asia who use paan (betel quid) in the mouth should be aware that this habit has been strongly associated with an increased risk for oral cancer. Also, consumption of mate, a tea-like beverage habitually consumed by South Americans, has been associated with an increased risk of cancers of the mouth, throat, esophagus, and larynx.

    People who are at risk for head and neck cancers should talk with their doctor about ways they can reduce their risk. They should also discuss how often to have checkups.

     

  5. What are common symptoms of head and neck cancers?

    Symptoms of several head and neck cancer sites include a lump or sore that does not heal, a sore throat that does not go away, difficulty swallowing, and a change or hoarseness in the voice. Other symptoms may include the following:

    • Oral cavity. A white or red patch on the gums, tongue, or lining of the mouth; a swelling of the jaw that causes dentures to fit poorly or become uncomfortable; and unusual bleeding or pain in the mouth.
    • Nasal cavity and sinuses. Sinuses that are blocked and do not clear, chronic sinus infections that do not respond to treatment with antibiotics, bleeding through the nose, frequent headaches, swelling or other trouble with the eyes, pain in the upper teeth, or problems with dentures.
    • Salivary glands. Swelling under the chin or around the jawbone; numbness or paralysis of the muscles in the face; or pain that does not go away in the face, chin, or neck.
    • Oropharynx and hypopharynx. Ear pain.
    • Nasopharynx. Trouble breathing or speaking, frequent headaches, pain or ringing in the ears, or trouble hearing.
    • Larynx. Pain when swallowing, or ear pain.
    • Metastatic squamous neck cancer. Pain in the neck or throat that does not go away.

    These symptoms may be caused by cancer or by other, less serious conditions. It is important to check with a doctor or dentist about any of these symptoms.

    medical history, performs a physical examination, and orders diagnostic tests. The exams and tests conducted may vary depending on the symptoms. Examination of a sample of tissue under the microscope is always necessary to confirm a diagnosis of cancer.

    Some exams and tests that may be useful are described below:

    • Physical examination may include visual inspection of the oral and nasal cavities, neck, throat, and tongue using a small mirror and/or lights. The doctor may also feel for lumps on the neck, lips, gums, and cheeks.
  • Endoscopy is the use of a thin, lighted tube called an endoscope to examine areas inside the body. The type of endoscope the doctor uses depends on the area being examined. For example, a laryngoscope is inserted through the mouth to view the larynx; an esophagoscope is inserted through the mouth to examine the esophagus; and a nasopharyngoscope is inserted through the nose so the doctor can see the nasal cavity and nasopharynx.
  •  
    1. How are head and neck cancers diagnosed?

      To find the cause of symptoms, a doctor evaluates a person’s

    • Laboratory tests examine samples of blood, urine, or other substances from the body.
    • X-rays create images of areas inside the head and neck on film.
    • CT (or CAT) scan is a series of detailed pictures of areas inside the head and neck created by a computer linked to an x-ray machine.
    • Magnetic resonance imaging (or MRI) uses a powerful magnet linked to a computer to create detailed pictures of areas inside the head and neck.

     

  • PET scan uses sugar that is modified in a specific way so it is absorbed by cancer calls and appears as dark areas on the scan.

     

  • Biopsy is the removal of tissue. A pathologist studies the tissue under a microscope to make a diagnosis. A biopsy is the only sure way to tell whether a person has cancer.

If the diagnosis is cancer, the doctor will want to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in the operating room), x-rays and other imaging procedures, and laboratory tests. Knowing the stage of the disease helps the doctor plan treatment.

  1. What health professionals treat patients with head and neck cancers?

    Patients with head and neck cancers are best treated by a team of specialists. The specialists vary, depending on the location and extent of the cancer. The medical team may include oral surgeons; ear, nose, and throat surgeons (also called otolaryngologists); pathologists; medical oncologists; radiation oncologists; prosthodontists; dentists; plastic surgeons; dietitians; social workers; nurses; physical therapists; and speech-language pathologists (sometimes called speech therapists).

  2.  
  3. How are head and neck cancers treated?

    The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person’s age and general health. The patient and the doctor should consider treatment options carefully. They should discuss each type of treatment and how it might change the way the patient looks, talks, eats, or breathes.

     

    • Surgery. The surgeon may remove the cancer and some of the healthy tissue around it. Lymph nodes in the neck may also be removed (lymph node dissection), if the doctor suspects that the cancer has spread. Surgery may be followed by radiation treatment.

      Head and neck surgery often changes the patient’s ability to chew, swallow, or talk. The patient may look different after surgery, and the face and neck may be swollen. The swelling usually goes away within a few weeks. However, lymph node dissection can slow the flow of lymph, which may collect in the tissues; this swelling may last for a long time. After a laryngectomy (surgery to remove the larynx), parts of the neck and throat may feel numb because nerves have been cut. If lymph nodes in the neck were removed, the shoulder and neck may be weak and stiff. Patients should report any side effects to their doctor or nurse, and discuss what approach to take. Information about rehabilitation can be found in question 10.

       

    • Radiation therapy , also called radiotherapy. This treatment involves the use of high-energy x-rays to kill cancer cells. Radiation may come from a machine outside the body (external radiation therapy). It can also come from radioactive materials placed directly into or near the area where the cancer cells are found (internal radiation therapy or radiation implant).

      In addition to its desired effect on cancer cells, radiation therapy often causes unwanted effects. Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth; a dry mouth or thickened saliva; difficulty in swallowing; changes in taste; or nausea. Other problems that may occur during treatment are loss of taste, which may decrease appetite and affect nutrition, and earaches (caused by hardening of the ear wax). Patients may also notice some swelling or drooping of the skin under the chin and changes in the texture of the skin. The jaw may feel stiff and patients may not be able to open their mouth as wide as before treatment. Patients should report any side effects to their doctor or nurse and ask how to manage these effects.

      More information about radiation therapy is available in the NCI booklet Radiation Therapy and You: A Guide to Self-Help During Treatment. NCI publications and materials are available by calling the Cancer Information Service (CIS) at 1–800–4–CANCER (1–800–422–6237), or through the NCI Publications Locator Web site at http://www.cancer.gov/publications on the Internet.

       

    • Chemotherapy, also called anticancer drugs. This treatment is used to kill cancer cells throughout the body. The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, including blood cells that fight infection, cells that line the mouth and the digestive tract, and cells in hair follicles. As a result, patients may have side effects such as lower resistance to infection, sores in the mouth and on the lips, loss of appetite, nausea, vomiting, diarrhea, and hair loss. They may also feel unusually tired and experience skin rash and itching, joint pain, loss of balance, and swelling of the feet or lower legs. Patients should talk with their doctor or nurse about the side effects they are experiencing, and how to handle them. The NCI booklet Chemotherapy and You: A Guide to Self-Help During Treatment has more information about this type of treatment.

      Additional information on treatment for head and neck cancers can be found in the following PDQ® cancer treatment summaries, available in patient and health professional versions, at http://www.cancer.gov/cancertopics/pdq/adulttreatment on the Internet:

       

      • Hypopharyngeal Cancer
      • Laryngeal Cancer
      • Lip and Oral Cavity Cancer
      • Nasopharyngeal Cancer
      • Oropharyngeal Cancer
      • Paranasal Sinus and Nasal Cavity Cancer
      • Salivary Gland Cancer

     

  4. Are clinical trials (research studies) available for patients with head and neck cancers?

    Clinical trials are research studies conducted with people who volunteer to take part. Participation in clinical trials is an option for many patients with head and neck cancers.

    Treatment trials are designed to find more effective cancer treatments and better ways to use current treatments. In some studies, all patients receive the new treatment. In others, doctors compare different therapies by giving the new treatment to one group of patients and standard therapy to another group. Doctors are studying new types and schedules for delivering radiation therapy, new anticancer drugs, new drug combinations, and new ways of combining treatments. They are also studying ways to treat head and neck cancers using biological therapy (a type of treatment that stimulates the immune system to fight cancer) by itself or in combination with anticancer drugs or radiation therapy.

    Scientists are also conducting clinical trials to find better ways to reduce the side effects of chemotherapy and radiation therapy for head and neck cancers. These clinical trials, called supportive care trials, explore ways to improve the comfort and quality of life of cancer patients and cancer survivors.

    People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from the CIS (see below) and the NCI booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know. This booklet describes how research studies are carried out and explains their possible benefits and risks. In addition, the NCI’s Web site, http://www.cancer.gov on the Internet, provides information about clinical trials. It also offers detailed information about specific ongoing studies by linking to PDQ, a cancer information database developed by NCI. The CIS also provides information from PDQ.

  5. What rehabilitation or support options are available for patients with head and neck cancers?

    Rehabilitation is a very important part of treatment for patients with head and neck cancer. The goals of rehabilitation depend on the extent of the disease and the treatment a patient has received. The health care team makes every effort to help the patient return to normal activities as soon as possible.

  6.  
  7. Depending on the location of the cancer and the type of treatment, rehabilitation may include physical therapy, dietary counseling, speech therapy, and/or learning how to care for a stoma after a laryngectomy. A stoma is an opening into the windpipe through which a patient breathes after a laryngectomy.

    Sometimes, especially with cancer of the oral cavity, a patient may need reconstructive and plastic surgery to rebuild the bones or tissues of the mouth. If this is not possible, a prosthodontist may be able to make a prosthesis (an artificial dental and/or facial part) to restore satisfactory swallowing and speech. Patients will receive special training to use the device.

    Patients who have trouble speaking after treatment, or who have lost their ability to speak, may need speech therapy. Often, a speech-language pathologist will visit the patient in the hospital to plan therapy and teach speech exercises or alternative methods of speaking. Speech therapy usually continues after the patient returns home.

    Eating may be difficult after treatment for head and neck cancer. Some patients receive nutrients directly into a vein (IV) after surgery, or need a feeding tube until they can eat on their own. A feeding tube is a flexible plastic tube that is passed into the stomach through the nose or an incision (cut) in the abdomen. A nurse or speech-language pathologist can help patients learn how to swallow again after surgery. The NCI booklet Eating Hints for Cancer Patients: Before, During, and After Treatment contains many useful suggestions and recipes.

  8. Is follow-up treatment necessary? What does it involve?

    Regular follow-up care is very important after treatment for head and neck cancer to make sure the cancer has not returned, or that a second primary (new) cancer has not developed. Depending on the type of cancer, medical checkups could include exams of the stoma, mouth, neck, and throat. Regular dental exams may also be necessary. From time to time, the doctor may perform a complete physical exam, blood tests, x-rays, and CT, PET, or MRI scans. The doctor may continue to monitor thyroid and pituitary gland function, especially if the head or neck was treated with radiation. Also, the doctor is likely to counsel patients to stop smoking. Research has shown that continued smoking may reduce the effectiveness of treatment and increase the chance of a second primary cancer (see question 12). The NCI fact sheet Follow-up Care: Questions and Answers has more information about this topic.

  9. What can people who have had head and neck cancer do to reduce the risk of developing a second primary (new) cancer?

    People who have been treated for head and neck cancer have an increased chance of developing a new cancer, usually in the head and neck, esophagus, or lungs. The chance of a second primary cancer varies depending on the original diagnosis, but is higher for people who smoke and drink alcohol. Patients who do not smoke should never start. Those who smoke should do their best to quit. Studies have shown that continuing to smoke or drink (or both) increases the chance of a second primary cancer for up to 20 years after the original diagnosis. Information about smoking cessation is available from the CIS (see below) and in the NCI fact sheet Questions and Answers About Smoking Cessation.

    Some research has shown that isotretinoin (13-cis-retinoic acid), a substance related to vitamin A, may reduce the risk of the tumor recurring (coming back) in patients who have been successfully treated for cancers of the oral cavity, oropharynx, and larynx. However, treatment with isotretinoin has not yet been shown to improve survival or to prevent future cancers.
 
Detailed Guide: Laryngeal and Hypopharyngeal Cancer
Can Laryngeal and Hypopharyngeal Cancer Be Found Early?
Many laryngeal and some hypopharyngeal cancers can be found early. Talk to your doctor if you have any of these symptoms. Many of these signs and symptoms may be caused by other cancers or by less serious, benign problems. Nonetheless, it is important to see a doctor to find out whether your symptoms are caused by a cancer or a noncancerous condition. The sooner you receive a correct diagnosis, the sooner you can start treatment and the more effective your treatment will be.

Signs and Symptoms of Glottic Cancer

Laryngeal cancers that form on the vocal cords (glottis) are often found at a very early stage because even small tumors in this area can cause hoarseness. Hoarseness that does not improve within 2 weeks should be checked by a doctor.

A complete head and neck examination that includes laryngoscopy (viewing of the vocal cords and larynx) should be done. This examination requires special equipment and is usually done by head and neck surgeons or otolaryngologists (ear, nose, and throat specialists). Laryngoscopy is discussed further in the section "How Are Laryngeal and Hypopharyngeal Cancers Diagnosed?".

Signs and Symptoms of Supraglottic, Subglottic, and Hypopharyngeal Cancers

Cancers that start in the area of the larynx above the vocal cords (supraglottis), the area below the vocal cords (subglottis), or the hypopharynx are usually discovered at later stages than those on the vocal cords.

Spread of Laryngeal and Hypopharyngeal Cancers

An important factor influencing how quickly cancers spread is the distribution of lymphatic vessels in different areas of the larynx and hypopharynx. Lymphatic vessels are small channels similar to veins except, instead of carrying blood, they carry lymph between lymph nodes and other tissues in your body. Lymph is a clear fluid that contains immune system cells. Lymph nodes are bean-shaped collections of immune system cells that help fight infection and cancers.

Although lymphatic vessels help to keep body tissues healthy, they also can provide a path for cancer cells to spread along. One of the reasons glottic cancers do not spread early is that the vocal cords contain very few lymphatic vessels. On the other hand, other areas of the larynx and hypopharynx contain many lymphatic vessels, making it easier for cancers starting there to spread to lymph nodes and other parts of your body.

The symptoms of cancer in these areas are less clear and may include:

  • A sore throat that won’t go away
  • Constant coughing
  • Pain when swallowing
  • Difficulty swallowing
  • Ear pain that won’t go away
  • Difficulty breathing
  • Weight loss
  • Hoarseness that lasts more than 2 weeks
  • A lump or mass in the neck

Hoarseness occurs only after these cancers reach a later stage or have spread to the vocal cords. These cancers are sometimes not found until they have spread to the lymph nodes and the patient notices a growing mass in the neck.

 
Detailed Guide: Nasopharyngeal Cancer
Can Nasopharyngeal Cancer Be Found Early?
Some cases of nasopharyngeal cancer (NPC) can be found early in the course of the disease because they result in symptoms that cause patients to seek medical attention. The symptoms may even seem unrelated to the nasopharynx (e.g., in adults, persistent fullness in one ear). In some other cases, nasopharyngeal cancers may not cause symptoms until they have reached an advanced stage. Most of the time, however, the cancer spreads quickly to lymph nodes in the neck before any symptoms occur. Over 80% of patients are in an advanced stage (stage III or IV -- see section on staging below) when they are diagnosed.

 

Computed Tomography (CT) - Head
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Computed Tomography (CT or CAT scan) equipment

More images
 

 

What is CT Scanning of the Head?

Computed tomography (CT), sometimes called CAT scan, uses special x-ray equipment to obtain many images from different angles, and then join them together to show a cross-section of body tissues and organs. CT scanning provides more detailed information on head injuries, stroke, brain tumors, and other brain diseases than do regular radiographs (plain x-ray films). It also can show bone, soft tissues and blood vessels in the same images. CT of the head and brain is a patient-friendly exam that involves radiation exposure.

 

 

Two different views of CT brain angiogram reveal an aneurysm (arrows) arising from the basilar artery.What are some common uses of the procedure?

  • Detection of bleeding, brain damage and skull fractures in patients with head injuries.
  • Detecting a blood clot or bleeding within the brain shortly after a patient exhibits symptoms of a stroke.
  • Detection of stroke, especially with a new technique called Perfusion CT.
  • Evaluation of the extent of bone and soft tissue damage in patients with facial trauma, and planning surgical reconstruction.
  • Detection of bleeding in a patient with a sudden severe headache who may have a ruptured or leaking aneurysm. 
  • Detection of most brain tumors.
  • Diagnosing diseases of the temporal bone on the side of the skull, which may cause hearing problems.
  • Detection of enlarged brain cavities (ventricles) in patients with hydrocephalus.
  • Determining whether inflammation or other changes are present in the paranasal sinuses.
  • Planning radiation therapy for cancer of the brain or other tissues.
  • Guiding the passage of a needle used to obtain a tissue sample (biopsy) from the brain.
  • Non-invasive assessment of aneurysms or arteriovenous malformations through a technique called CT angiography.
  • Detecting diseases or malformations of the skull.
  • Three-dimensional imaging of the skull and brain structures.

 

How should I prepare for the CAT scan?

You should wear comfortable, loose-fitting clothing for your CT exam. Anything that might interfere with imaging of the head—such as earrings, eyeglasses, dentures, dental implants or hairpins—should be removed.

No special preparation is needed for a CT scan of the head unless you are to receive a contrast material—a substance that highlights the brain and its blood vessels and makes abnormalities easier to see. If the radiologist believes that an intravenous (IV) injection of a contrast material will be helpful, you will be asked in advance whether you have had allergies in the past or have ever had a serious reaction to medication. CT scan contrast materials contain iodine, which can cause such a reaction in persons who are allergic. If you have known allergies to other medications it may raise the possibility that you might have an allergic reaction to the contrast material. The radiologist also should know if you have asthma, multiple myeloma or any disorder of the heart, kidneys or thyroid gland, or if you have diabetes—particularly if you are taking Glucophage. Typically you will be asked to sign an informed consent form before having CT with injection of a contrast material.

Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant. In some cases an alternate study will be performed to reduce or eliminate the radiation exposure to the fetus.

 

What does the equipment look like?

The CT scanner is a large, square machine with a hole in the center, something like a doughnut. The patient lies still on a table that can move up or down and slide into and out of the center of the hole. Within the machine, an x-ray tube on a rotating gantry (or frame) moves around the patient's body to produce the images, making clicking and whirring noises as the arm moves. Though the technologist will be able to see and speak to you, you will be alone in the room during the exam.

An example of the radiography equipment that may be used is shown above.

 

How does the procedure work?

Normal head CAT scan with intravenous contrast.Unlike conventional x-rays, which produce pictures of the shadows cast by body structures of different density, CT scanning uses x-rays in a much different way. In CT of the head, numerous x-ray beams are passed through the skull and brain at different angles, and special sensors measure the amount of radiation absorbed by different tissues (and lesions such as a bleeding tumor). As you lie still, the scanner parts revolve around you (although you cannot see this happen), emitting and recording x-ray beams from as many as a thousand points on the circle. A special computer program then uses the differences in x-ray absorption to form cross-sectional images, or "slices" of the head and brain. These slices are called tomograms, hence the name "computed tomography."

 

How is the CAT scan performed?

CT scanning of the head may be performed in the hospital or at an outpatient radiology center, but in either case your doctor must give you a written referral with the reason why the study should be performed. You will lie on a table that is guided into the center of the scanner and you will be asked to lie very still.

As stated earlier, some patients will require an injection of a contrast material to enhance the visibility of certain tissues or blood vessels. A small needle connected to an intravenous line is placed in an arm or hand vein. The contrast material will be injected through this line.

Depending on the number of images needed, a CT exam of the head and brain can take between two and 20 minutes. When it is completed you will be asked to wait until the technologist examines the images to determine if more are needed.

 

What will I experience during the procedure?

When you enter the scanner, special lights may be turned on to ensure correct positioning. Some types of exam (such as a scan of the sinuses) call for a special head holder that uses soft straps to keep the head and neck in proper alignment. In some cases you will lie on your stomach; in others on your back. The patient and technologist can talk at any time via an intercom.

CT itself causes no pain, though there may be some discomfort from the need to remain still. If contrast material is injected you may have a warm, flushed sensation during the injection. You may also experience a metallic taste in your mouth that lasts for about two minutes. Occasionally a patient will develop itching and hives for up to a few hours after the injection; this can be relieved by medication. If you develop light-headedness or difficulty breathing, it may indicate a more severe allergic reaction—a physician or nurse will be present nearby to assist you.

Because CT uses x-rays, you may not have a relative or friend in the CT room during the exam.

 

Who interprets the results and how do I get them?

A radiologist, who is a physician experienced in CT and other radiology examinations, will analyze the images and provide a signed report with his or her interpretation to the patient's referring physician. The patient receives the results from the referring physician who ordered the test. New technology also allows for distribution of diagnostic reports and referral images over the Internet at many facilities.

Top

 

What are the benefits vs. risks?

Benefits

  • CT of the head is now widely available and is performed in a relatively short time, at a reasonable cost—especially when compared to MR imaging.
  • The exam shows some changes in bone better than any other imaging method.
  • It readily detects bleeding.
  • The exam is used for stroke detection.
  • It provides detailed images of bone, soft tissue and blood vessels.
  • CT is the method of choice for rapidly screening trauma victims to detect internal bleeding or other life-threatening conditions.
  • CT Angiography depicts brain blood vessels, revealing aneurysms and occlusion.

Risks

  • CT does involve exposure to radiation in the form of x-rays, but the benefit of an accurate diagnosis far outweighs the risk. The effective radiation dose from this procedure is about 2 mSv, which is about the same as the average person receives from background radiation in eight months. See the Safety page for more information about radiation dose.
  • Special care is taken during x-ray examinations to ensure maximum safety for the patient by shielding the abdomen and pelvis with a lead apron, with the exception of those examinations in which the abdomen and pelvis are being imaged. Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant.
  • Nursing mothers should wait 24 hours after contrast injection before resuming breast feeding.
  • The risk of serious allergic reaction to iodine-containing contrast material is rare and personnel working at CT units are well equipped to deal with them.

 

 What are the limitations of CT Scanning of the Head?

Compared to MR imaging, the precise details of soft tissue (particularly the brain) are less visible on CT scans. CT is not sensitive in detecting inflammation of the meninges—the membranes covering the brain.

Compared to conventional angiography, computed tomography angiography (CTA) may, in some cases, not be as sensitive in the detection of aneurysms and arteriovenous malformations of the brain.
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Detailed Guide: Laryngeal and Hypopharyngeal Cancer
How Are Laryngeal and Hypopharyngeal Cancer Staged?
Staging is the process of finding out how far a cancer has spread. The extent of spread of laryngeal or hypopharyngeal cancer is the most important factor in selecting treatment options and estimating a patient's outlook for recovery and survival (prognosis). A staging system is a way for members of the cancer care team to summarize the extent of a cancer's spread.

If you have laryngeal or hypopharyngeal cancer, ask your cancer care team to explain the staging of your cancer in a way that you understand. Knowing all you can about staging lets you take a more active role in making informed decisions about your treatment.

The American Joint Committee on Cancer (AJCC) TNM System

The most common system used to describe the stages of cancers is the American Joint Committee on Cancer (AJCC) TNM system. T stands for tumor (its size and how far it has spread within the larynx and hypopharynx and to nearby organs). N stands for spread to lymph nodes (bean-sized collections of immune system cells that help fight infections and cancers). M is for metastasis (spread to distant organs).

Using the TNM staging system, information about the tumor, lymph nodes, and metastasis is combined to assign a stage. This process is called stage grouping. The stage is described in Roman numerals from I to IV. Patients with lower stage cancers have a better prognosis for a cure or long-term survival.

The T stage of cancers of the larynx and hypopharynx depends on how far it has spread from its origin. Spread may be evaluated by indirect examinations using mirrors, by direct endoscopy using scopes, and, if your doctor can reach it, by feeling the texture of the area.

Watching movement of the vocal cords with special mirrors while the patient makes certain sounds can tell the doctors about the extent of local spread. If your vocal cords move normally, it is unlikely that the cancer has affected deeper tissues. Vocal cord fixation (lack of movement) suggests involvement by cancer. Imaging studies such as CT or MRI scans may be used to add more detailed information.

T staging of laryngeal and hypopharyngeal cancers describes spread of the cancer precisely in relation to specific areas of the larynx, hypopharynx, and the surrounding structures. These areas are shown in an illustration in the section "What Is Laryngeal and Hypopharyngeal Cancer?" Higher T stage numbers indicate more spread within the larynx or hypopharynx and to other nearby areas in the neck.

The features used to assign the T stage of laryngeal cancer vary according to the area of the larynx involved--supraglottis, glottis, or subglottis. T staging for hypopharyngeal cancer differs from T staging for cancer of the larynx.
T Stages Common to All Laryngeal and Hypopharyngeal Cancers
TX: Cannot be staged (information not available)
T0: No evidence of tumor
Tis: Carcinoma in situ. The cancer cells are limited to the epithelium, and there is no growth into the connective tissue of the larynx or hypopharynx. (Very few hypopharyngeal and larynx cancers are found at this early stage.)
T Stages of Supraglottic Cancer

The T stage of cancer of the supraglottis is based on how many subsites (different parts of the larynx) are involved and how far outside the larynx the cancer has spread. The 5 subsites of the supraglottic part of the larynx are the ventricular bands (also called false vocal cords), arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, and aryteno-epiglottic folds.

T1: The tumor is limited to 1 subsite of the supraglottis, and thevocal cords move normally.

T2: The tumor invades more than 1 subsite of the supraglottis, and the vocal cords move normally.

T3: The tumor is limited to the larynx, and there is vocal cord fixation (lack of movement) and/or invasion of the postcricoid area, paraglottic space, or pre-epiglottic (in front of the epiglottis) tissues.

T4a: The tumor invades through thyroid cartilage (firm tissue that separates the thyroid gland from the front of the larynx) and/or extends to tissues beyond the larynx.
T4b: The tumor invades prevertebral (in front of the vertebrae) space, encases a carotid artery, or invades into mediastinal (chest) structures.
T Stages of Glottic Cancer
T1: The tumor is limited to the vocal cord(s), and the vocal cords move normally.

T1a: The tumor is limited to 1 vocal cord.
T1b: The tumor is on both vocal cords.
T2: The tumor extends to the supraglottis and/or subglottis, and/or there is impaired vocal cord movement.
T3: The tumor is limited to the larynx with vocal cord fixation and/or invades the paraglottic space, and/or there is minor erosion of thyroid cartilage (firm tissue that separates the thyroid gland from the front of the larynx).
T4a: The tumor invades through thyroid cartilage and/or extends to tissues beyond the larynx.
T4b: The tumor invades prevertebral (in front of the vertebrae) space, surrounds a carotid artery, or invades into mediastinal (chest) structures.
T Stages of Subglottic Cancer
T1: The tumor is limited to the subglottis.
T2: The tumor extends to the vocal cords, with or without impaired vocal cord movement.
T3: The tumor is limited to the larynx with vocal cord fixation (lack of movement).
T4a: The tumor invades through the cricoid or thyroid cartilage and/or extends to tissues beyond the larynx.
T4b: The tumor invades prevertebral (in front of the vertebrae) space, encases a carotid artery, or invades into chest structures.
T Stages of Hypopharyngeal Cancer
Spread of cancer within the hypopharynx is described according to the size of the tumor and how many subsites (areas of the hypopharynx) are involved by the cancer. The 3 subsites of the hypopharynx are the pharyngo-esophageal junction, pyriform sinus, and posterior pharyngeal wall.
T1: The tumor is limited to 1 subsite of the hypopharynx and is smaller than 2 centimeters (cm) (about 3/4 of an inch) in diameter
T2: The tumor involves more than 1 subsite of the hypopharynx or an adjacent site or is 2 to 4 cm, without vocal cord fixation.
T3: The tumor is larger than 4 cm in diameter or involves vocal cord fixation.
T4a: The tumor invades the cricoid or thyroid cartilage, hyoid bone, thyroid gland, esophagus, or the strap muscles in front of the larynx.
T4b: The tumor invades the space in front of the vertebrae, encases a carotid artery, or invades into chest structures.
N (Regional Lymph Node) Stages of Laryngeal and Hypopharyngeal Cancers
The N staging is the same for laryngeal and hypopharyngeal cancers. The stages are as follows:
NX: The lymph nodes cannot be assessed (information not available).
N0: There is no evidence of spread to the lymph nodes.
N1: The cancer has spread to a single lymph node not larger than 3 cm (about 1Ľ inch) in diameter. The lymph node is on the same side of the neck (right or left) as the primary tumor.
N2: There is spread to 1 or more lymph node(s) between 3 cm and 6 cm (about 2˝ inches) in diameter.
N2a: There is spread in 1 lymph node between 3 cm and 6 cm, on the same side of the neck as the origin of the cancer.
N2b: There is spread in multiple lymph nodes, none larger than 6 cm, and all on the same side of the neck as the origin of the cancer.
N2c: There is spread to 1 or more lymph nodes on both sides of neck or on the side opposite the origin of the cancer. None can be larger than 6 cm.
N3: There is spread to 1 or more lymph nodes larger than 6 cm.
M (Distant Metastasis) Stages of Laryngeal and Hypopharyngeal Cancers
The M staging for all head and neck cancers, including laryngeal and hypopharyngeal cancers, is the same. The stages are as follows:
MX: Information not available. Unable to tell if distant metastasis is present.
M0: No distant metastasis.
M1: Distant metastasis present.

Stage Grouping

Once the T, N, and M stages have been assigned, this information is combined (called stage grouping) to assign an overall stage of 0, I, II, III, or IV. Stage grouping rules are the same for all cancers of the hypopharynx and the supraglottic, glottic, and subglottic areas of the larynx.

Stage 0: Tis, N0, M0
Stage I: T1, N0, M0
Stage II: T2, N0, M0
Stage III: T1, N1, M0 or
T2, N1, M0 or
T3, N0, M0 or
T3, N1, M0
Stage IVA: T1, N2, M0, or
T2, N2, M0, or
T3, N2, M0, or
T4a, N0, M0, or
T4a, N1, M0, or
T4a, N2, M0
Stage IVB: T4b,
 Any N, M0, or
Any T, N3, M0
Stage IVC: Any T, Any N, M1

If you have any questions about the stage of your cancer or how it affects your treatment, do not hesitate to ask your doctor.

Revised: 01/01/2005
Detailed Guide: Laryngeal and Hypopharyngeal Cancer
How Are Laryngeal and Hypopharyngeal Cancer Diagnosed?
If you have signs or symptoms that suggest a cancer of the larynx or hypopharynx might be present, your doctor will recommend 1 or more of the following tests or procedures. (Signs and symptoms of these cancers are discussed in the section, "Can Laryngeal and Hypopharyngeal Cancer Be Found Early").

Examinations and Procedures for Evaluating Suspected Laryngeal or Hypopharyngeal Cancer

Complete medical history and physical examination: The first step in any medical evaluation is for your doctor to gather information about symptoms, risk factors, and family history and medical conditions. A thorough physical exam will help uncover any signs of possible cancer or other diseases.

Blood tests: Blood tests are not used to diagnose tumors of the larynx or hypopharynx. Routine blood tests, however, help evaluate a patient's overall medical condition. This is particularly important if surgery is being considered.

Consultation with a specialist: If your doctor suspects a cancer of the larynx or hypopharynx, you will be referred to see an otolaryngologist (head and neck surgeon) for a complete evaluation.

Complete head and neck exam including nasopharyngoscopy and laryngoscopy: In addition to a complete general physical exam, special attention to the head and neck area is important. Because the larynx and hypopharynx are deep inside the neck and not easily seen, special mirrors and fiber-optic laryngoscopes (flexible, lighted, narrow tubes inserted through the mouth or nose) are used to examine these areas. Indirect laryngoscopy uses mirrors to look at the larynx. Direct laryngoscopy is done with fiber-optic scopes.

Because patients with laryngeal or hypopharyngeal cancer have a higher risk for other cancers in the head and neck region, the nasopharynx (area behind the nose), mouth, tongue, and the neck are carefully looked at and felt for any evidence of cancer.

Panendoscopy (including laryngoscopy, esophagoscopy, and possible bronchoscopy): If your doctor highly suspects a cancer in the head and neck, he or she will thoroughly examine the larynx, hypopharynx, esophagus, and the trachea and bronchi (breathing tubes of the lungs). This examination, called a panendoscopy, is done in the operating room while you are under general anesthesia (asleep).

Your doctor will look at the area through a scope to determine the size of any tumor and how much it may have spread to surrounding areas. A biopsy (removal of a tissue sample for examination under a microscope) may be performed with a special instrument operated through the scope. Fiber-optic scopes are also used to check the esophagus and, possibly, the trachea and bronchi.

Imaging Techniques for Evaluating Laryngeal and Hypopharyngeal Cancers

Once a tumor is detected by examination, imaging studies may be useful in determining the extent of spread.

Computed tomography (CT or CT scan): The CT scan (also known as a CAT scan) is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine takes pictures of multiple slices of the part of your body being studied. This test can help your doctor determine the size of the tumor, whether it is growing into nearby tissues, and if it has spread to lymph nodes in the neck.

CT scans take longer than regular x-rays, and you need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your scan might be pleasantly short.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of your body. Not only does this produce cross-sectional slices of the body like a CT scanner, it also produces slices that are parallel with the length of your body.

A contrast material might be injected just as with CT scans. MRI scans provide the same kind of information that CT scans do, but sometimes they can provide a different and more helpful picture.

MRI scans take longer than CT scans—often up to an hour. Also, you are placed inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. The machine makes a thumping noise, and some places will provide headphones with music to block out the noise.

Barium swallow: This is a series of x-rays taken while the patient swallows a barium-containing liquid that can be seen on the x-rays. It is useful in examining your throat while you swallow and can show your doctor what your hypopharynx looks like.

Chest x-ray: Because smoking causes lung cancer and emphysema, as well as laryngeal and hypopharyngeal cancers, a chest x-ray is routinely done to see if cancer is present in the lungs. If any suspicious spots are noted on the chest x-ray, a CT scan of the chest may be needed.

For more information on these tests, see our document "Imaging (Radiology) Tests."

Types of Biopsies Used to Diagnose Laryngeal and Hypopharyngeal Cancers

A biopsy is a procedure that removes a sample of tissue for examination under the microscope. It is the only way to confirm the diagnosis of cancer.

Endoscopic biopsy: Because the larynx and hypopharynx are located deep inside the neck, biopsies of these areas are not done in the doctor's office. These are performed in the operating room while you are under general anesthesia (asleep). The surgeon uses special instruments through an endoscope to remove small tissue samples.

Fine needle aspiration (FNA) biopsy: If you have a lump in your neck, an FNA biopsy (a thin needle placed into the mass so that cells can be withdrawn to check under a microscope) can determine if it is a benign lymph node that has grown in reaction to a nearby infection, (such as a sinus or tooth infection), a benign fluid-filled cyst that can be cured by surgery, or cancer.

Even when the FNA results are benign, if you have symptoms suggesting a laryngeal or hypopharyngeal cancer, you will need additional procedures (such as laryngoscopy or panendoscopy). If the FNA finds cancer, the pathologist (a doctor specializing in diagnosing disease by laboratory tests) examining the specimen can often tell what type of cancer it is. If the type of cancer seen is consistent with cancers that begin in the larynx or hypopharynx, these areas are examined also.

FNA biopsies may be useful in other situations as well. If a patient with laryngeal or hypopharyngeal cancer has a neck mass that can be felt, an FNA can help determine if the mass is due to the spread of the cancer. FNA may also be used in patients whose laryngeal or hypopharyngeal cancer has been treated by surgery and/or radiation therapy, to find out if a new neck mass in the treated area is scar tissue, or to find out if your cancer has come back (recurred).

Revised: 01/01/2005
Detailed Guide: Nasopharyngeal Cancer
How Is Nasopharyngeal Cancer Diagnosed?
This cancer is diagnosed when a patient complains of symptoms or finds a lump in the neck.

Symptoms and Signs of Nasopharyngeal Cancer

Some patients with NPC have no symptoms at all. But, as many as 90% of patients complain of a lump or tumor mass in the neck area when they first see their doctor. This is often caused by the cancer spreading to lymph nodes in the neck. In about one third of NPC patients, a neck mass is the only apparent sign of cancer. Other common symptoms of NPC include hearing loss (especially on one side only), nasal blockage or stuffiness, pain, nosebleeds, difficulty opening the mouth, and blurred or double vision (related to invasion of the nerves that control eye movement).

A number of benign conditions can also produce some of these symptoms. However, a medical evaluation is the only way to be sure NPC is not present. If you have any of these signs or symptoms, discuss them with your doctor without delay.

Medical history and physical examination: The first step is to have your health care professional take a complete medical history (interview) to check for risk factors and symptoms. A physical exam will provide other information about signs of nasopharyngeal cancer (NPC) and other health problems. During your physical exam, the doctor will pay special attention to any visible abnormality in the nasopharynx, lymph node enlargement in the neck area, facial numbness or muscle weakness (possibly due to spread of cancer into nerves), and any other associated health problems.

Examinations of the nasopharynx: Because the nasopharynx is located deep inside the head and not easily seen, special techniques are needed to examine this area. Indirect nasopharyngoscopy uses special mirrors and lights. Direct nasopharyngoscopy is done with fiberoptic scopes (flexible, lighted, narrow tubes inserted through the mouth or nose). These instruments allow the doctor to look inside the nasopharynx for abnormal growths, bleeding, or other signs of disease.

If a suspicious growth is found, a biopsy is usually done to obtain a sample of tissue. In this procedure, the doctor uses small instruments, with the aid of a fiberoptic scope for a direct view, to cut out a small piece of tissue. The tissue specimen is sent to a laboratory, and a pathologist (a doctor specializing in laboratory diagnosis of diseases) looks at the tissue under a microscope. If cancer cells are present, the pathologist sends back a report describing the type and extent of the cancer.

Some cases of NPC may not have any sign of disease that can be seen. This is because most of the cancer is hidden beneath the surface. If the patient has symptoms suggesting NPC, the surgeon may take several samples of normal-appearing tissue that may contain cancer cells when viewed under the microscope.

Imaging Tests

Chest x-ray: A plain x-ray of your chest will be done to see if your cancer has spread to your lungs. This is very unlikely unless your cancer is far advanced. This x-ray can be done in any outpatient setting. If the results are normal, you probably don’t have cancer in your lungs.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine takes pictures of multiple slices of the part of your body that is being studied. Often after the first set of pictures is taken you will receive an intravenous injection of a "dye" or radiocontrast agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. The newest CT scanners take only seconds to complete the study. Also, you might feel a bit confined by the ring-like equipment you’re in when the pictures are being taken.

The contrast dye, if needed, is injected through an IV line. Some people are allergic to the dye and get hives or a flushed feeling. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Be sure to tell your doctor if you have ever had a reaction to any contrast material used for x-rays. If you have, you may need medicine before you can have such an injection during your test.

The CT scan will provide precise information about the size, shape, and position of a tumor and can help find enlarged lymph nodes that might contain cancer. CT scans or MRIs are important for finding cancer that has spread into the bones at the base of the skull. This is a common place for nasopharyngeal cancer to grow.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body.

A contrast material might be injected just as with CT scans. MRI scans take longer -- often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia. The machine makes a thumping noise that you may find annoying. Some places provide headphones with music to block this out. MRIs are also helpful in detecting cancer that has spread to the brain or spinal cord. They are important in finding if the cancer has spread into the bones at the base of the skull. This is a common place for nasopharyngeal cancer to grow.

Positron emission tomography (PET): PET uses glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. This test is useful to see if the cancer has spread to lymph nodes. PET scans are also useful when your doctor thinks the cancer has spread but doesn’t know where. Newer devices combine a CT scan and a PET scan to even better pinpoint the tumor.

Other Tests

Blood tests: In some patients, the blood level of EBV before and after treatment may be useful to determine a patient’s outcome. Also, routine blood tests help determine a patient's overall physical condition. These tests can help diagnose malnutrition, anemia (low red blood counts), liver disease, and kidney disease. And they may suggest the possibility of liver metastasis or bone metastasis from a nasopharyngeal cancer, prompting additional testing.

Fine needle aspiration (FNA): This type of biopsy can be done in the doctor’s office or clinic. Local anesthesia may be injected into the skin over a mass. In some cases, no anesthetic at all is needed. Your doctor places a thin needle directly into the mass for about 10 seconds and withdraws cells and a few drops of fluid. These cells are then viewed under a microscope to determine if they appear cancerous (malignant).

If a patient already known to have NPC has enlarged neck lymph nodes, FNA can be useful in determining whether the lymph node swelling is due to the spread of NPC. In patients with enlarged lymph nodes in the neck area, FNA can be useful in deciding whether the cause is the spread of cancer from somewhere else (such as the nasopharynx), a different cancer that begins in lymph nodes called a lymphoma, or lymph node swelling in response to an infection (reactive hyperplasia).

Detailed Guide: Nasopharyngeal Cancer
How Is Nasopharyngeal Cancer Staged?
The process of finding out how far a cancer has spread is called staging. The extent of spread of nasopharyngeal cancer (NPC) is the most important factor in selecting treatment options and estimating your outlook for recovery from treatment and for survival. If you have NPC, ask your cancer care team to explain the staging in a way that you understand. By knowing all you can about staging, you can take a more active role in making informed decisions about your treatment.

A staging system is a way for members of the cancer care team to summarize the extent of a cancer's spread. The most common system used to describe the spread of NPC is the TNM system created by the American Joint Committee on Cancer (AJCC).

  • T stands for tumor (its size and how far it has spread locally within the nasopharynx and to nearby tissues).
  • N stands for spread to lymph nodes (small bean-shaped collections of immune system cells that help the body fight infections and cancers).
  • M is for metastasis (spread to distant organs).

Additional letters or numbers appear after T, N, and M to provide more details about each of these factors. The numbers 0 through 4 indicate increasing severity. The letter X means "cannot be assessed because the information is not available." The letters "is" after the T stand for "in situ," which means the tumor is contained in one place and has not yet spread to a deeper layer of tissue. To assign a stage, information about the tumor, lymph nodes, and metastasis is combined according to a process called stage grouping (see later text).

T Stages for Nasopharyngeal Carcinoma

TX: Primary tumor cannot be assessed due to incomplete information

T0: No evidence of a primary tumor

Tis: Carcinoma in situ (cancer cells are present only in the surface layer of the nasopharynx but have not invaded into other layers)

T1: Tumor is limited to the nasopharynx

T2: Tumor has spread to tissues (but not bone) outside the nasopharynx

T2a: Cancer has spread to the oropharynx (the back of the mouth, below the soft palate, where the throat begins) and/or nasal cavity but no further

T2b: Cancer has also spread to the left or right sides of the upper part of the throat

T3: Tumor has spread to the sinuses or the bones near the nasopharynx

T4: Tumor has spread into the skull and/or cranial nerves (nerves in the head that lie near the nasopharynx and have special functions such as vision, smell, and eye movement), the hypopharynx (lower part of the throat), the eye, or its nearby tissues

N Stages for Nasopharyngeal Carcinoma

NX: Regional lymph nodes cannot be assessed due to incomplete information

N0: No regional lymph node spread

N1: Spread to 1 or more single lymph nodes, not larger than 6 cm (about 2˝ inches), in the same side of the neck as the original cancer

N2: Metastasis to lymph nodes, not larger than 6 cm, on both sides of the neck

N3: Metastasis to 1 or more lymph nodes that are larger than 6 cm and are located above the collarbone

M Stages for Nasopharyngeal Carcinoma

 

  MX: Presence of distant metastasis cannot be assessed

M0: No distant metastasis

M1: Distant metastasis is present, involving other organs in the body

TNM Stage Grouping

To help guide treatment decisions, several of these T, N, and M combinations can be grouped together into a simpler set of stages, which are described by Roman numerals 0 to IV. Patients with lower stage cancer have a better prognosis for a cure or long-term survival. Here are the grouped stages and the TNM combinations that define them.

Stage 0: Tis, N0, M0: The cancer is "in situ". It has not yet penetrated to a deeper layer of nasopharyngeal tissue and has not spread to lymph nodes or distant sites.

Stage I: T1, N0, M0: The tumor is only in the nasopharynx and has not spread to lymph nodes or distant sites.

Stage II: T2a or b, N0, M0, T1or 2, N1, M0: The tumor has spread to soft tissues of the nasal cavity and/or the oropharynx and has not spread to lymph nodes or distant sites. Or, the tumor can be either confined to the nasopharynx or spread to soft tissues and has spread to one or more single lymph nodes, not larger than 6 cm (about 2˝ inches), in the same side of the neck as the original cancer but not to distant sites.

Stage III: T1 or 2, N2, M0, T3, N0-2, M0: The tumor has spread to soft tissues of the nasal cavity and/or the oropharynx and to lymph nodes, not larger than 6 cm, on both sides of the neck but not to distant sites. Or, the tumor has spread to the sinuses or the bones near the nasopharynx and may or may not have spread to lymph nodes but not to distant sites

Stage IVA: T4, N0-2, M0: The tumor has spread to the skull and/or cranial nerves (nerves in the head that lie near the nasopharynx and have special functions such as vision, smell, eye movement), the hypopharynx (lower part of the throat), the eye, or its nearby tissues and may or may not have spread to lymph nodes smaller than 6 cm, but not to distant sites.

Stage IVB: Any T, N3, M0: The tumor is of any size but has spread to one or more lymph nodes that are larger than 6 cm and/or located above the collarbone area but not to distant sites.

Stage IVC: Any T, any N, M1: The tumor is of any size and may or may not have spread to lymph nodes but has spread to distant sites.

Recurrent: Cancer that has come back (recurred) after treatment has taken place is called recurrent disease. Recurrent NPC may return in the nasopharynx, neck, or another part of the body.

Survival by stage: Listed below is the 5-year relative survival for each of the 4 main stages. The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Five-year rates are used to produce a standard way of discussing prognosis. Of course, many people live much longer than 5 years. Five-year relative survival rates try to exclude patients dying of other diseases. This is done by subtracting a percentage of the population that is expected to die of other causes.

Keep in mind that 5-year survival rates are based on patients diagnosed and initially treated more than 5 years ago. Improvements in treatment often result in a more favorable outlook for recently diagnosed patients.

Stage 5-year survival
I 63%
II 52%
III 56%
IV 39%

Because nasopharyngeal cancers are so uncommon, these figures are based on small numbers and are not totally consistent. This explains why stage III has a better survival than stage II.

Revised: 02/24/2005
 
 

MR Imaging (MRI) - Head
Click images to view larger
Magnetic Resonance Imaging (MRI) equipmentMagnetic Resonance Imaging (MRI) equipment


 

More images
 

 

What is MRI of the Head?

Magnetic resonance imaging (MRI) uses radio waves and a strong magnetic field rather than x-rays to provide remarkably clear and detailed pictures of internal organs and tissues. This technique has proved very helpful to radiologists in diagnosing tumors of the brain as well as disorders of the eyes and the inner ear. It requires specialized equipment and expertise and allows evaluation of some body structures that may not be as visible with other imaging methods.

 

 What are some common uses of the MRI procedure?

MRI is the most sensitive exam for brain tumors, strokes, and certain chronic disorders of the nervous system such as multiple sclerosis. In addition, it is a useful means of documenting brain abnormalities in patients with dementia, and it is commonly used for patients with disease of the pituitary gland. MRI can detect tiny areas of tissue abnormality in patients with disease of the eyes or the inner ear.Top

How should I prepare for the procedure?

Because the strong magnetic field used for MRI will pull on any metal object implanted in the body, MRI staff will ask whether you have a prosthetic hip, heart pacemaker (or artificial heart valve), implanted port, infusion catheter (brand names Port-o-cath, Infusaport, Lifeport), intrauterine device (IUD), or any metal plates, pins, screws, or surgical staples in your body. Tattoos and permanent eyeliner may also create a problem. You will be asked if you have ever had a bullet or shrapnel in your body, or ever worked with metal. If there is any question of metal fragments, you may be asked to have an x-ray that will detect any such metal objects. Tooth fillings usually are not affected by the magnetic field, but they may distort images of the facial area or brain, so the radiologist should be aware of them. The same is true of braces, which may make it hard to "tune" the MRI unit to your body. You will be asked to remove anything that might degrade MRI images of the head, including hairpins, jewelry, eyeglasses, hearing aids, and any removable dental work.

The radiologist or technologist may ask about drug allergies and whether head surgery has been done in the past. If you might be pregnant, this should be mentioned. Some patients who undergo MRI of the head in an enclosed unit may feel confined or claustrophobic. If you are not easily reassured, a sedative may be administered. Roughly one in 20 patients will require medication.

What does the MRI equipment look like?

The conventional MRI unit is a closed cylindrical magnet in which the patient must lie totally still for several seconds at a time, and consequently may feel closed-in or truly claustrophobic. However, new patient-friendly designs are rapidly coming into routine use. The "short-bore" systems are wider and shorter and do not fully enclose the patient. Some newer units are open on all sides; however, the image quality may vary. New, more powerful magnets which allow highly detailed images of the brain are also coming into use nowadays. For the patient, such magnets (e.g. 3 Tesla systems) look and feel similar to standard magnets in use today.

Examples of the radiography equipment that may be used are shown at the top of this page.

How does the procedure work?

MRI is a unique imaging method because, unlike the usual radiographs (x-rays), radioisotope studies, and even CT scanning, it does not rely on radiation. Instead, radio waves are directed at protons, the nuclei of hydrogen atoms, in a strong magnetic field. The protons are first "excited" and then "relaxed," emitting radio signals, which can be computer-processed to form an image. In the body, protons are most abundant in the hydrogen atoms of water — the "H" of H2O — so that an MRI image shows differences in the water content and distribution in various body tissues. Even different types of tissue within the same organ, such as the gray and white matter of the brain, can easily be distinguished. Typically an MRI exam consists of two to six imaging sequences, each lasting two to 15 minutes. Each sequence has its own degree of contrast and shows a cross section of the head in one of several planes (right to left, front to back, upper to lower).

How is the procedure performed?

Magnetic Resonance Imaging (MRI) procedureThe patient is placed on a sliding table and a radio antenna device called a surface coil is positioned around the upper part of the head. After positioning the patient with the head inside the MRI gantry, the radiologist and technologist leave the room and the individual MRI sequences are performed. The patient is able to communicate with the radiologist or technologist at any time using an intercom. Also, many MRI centers allow a friend or, if a child is being examined, a parent, into the room. Depending on how many images are needed, the exam will generally take 15 to 45 minutes, although a very detailed study may take longer. The patient will be asked not to move during the actual imaging process, but between sequences some movement is allowed. Patients are generally required to remain still for only a few seconds at a time. Some patients will require an injection of a contrast material to enhance the visibility of certain tissues or blood vessels. A small needle connected to an intravenous line is placed in an arm or hand vein. A saline solution will drip through the intravenous line to prevent clotting until the contrast material is injected about two-thirds of the way through the exam.

When the exam is over the patient is asked to wait until the images are examined to determine if more images are needed.

 What will I experience during the MRI procedure?

MRI causes no pain, but there may be a feeling of claustrophobia from being closed-in or from the need to remain still. You may notice a warm feeling in the area under examination; this is normal, but if it bothers you the radiologist or technologist should be told. If a contrast injection is needed, there may be discomfort at the injection site, and you may have a cool sensation at the site during the injection. Most bothersome to many patients are the loud tapping or knocking noises heard at certain phases of imaging. Ear plugs may help. When the knocking and the slight vibration that may accompany it stops, you can reposition your arms.
 Who interprets the results and how do I get them?

A radiologist, who is a physician experienced in MRI and other radiology examinations, will analyze the images and send a signed report with his or her interpretation to the patient's personal physician. The personal physician's office will inform the patient on how to obtain the results. New technology also allows for distribution of diagnostic reports and referral images over the Internet at some facilities.

What are the benefits vs. risks?

Benefits

  • Images of the brain and other head structures are clearer and more detailed than with other imaging methods.
  • MRI contrast material is less likely to produce an allergic reaction than the iodine-based materials used for conventional x-rays and CT scanning.
  • MRI enables the detection of abnormalities that might be obscured by bone tissue with other imaging methods.
  • A variant called MR angiography (MRA) provides detailed images of blood vessels in the brain—oftentimes without the need for contrast material. The risk of an allergic reaction from MRA contrast is extremely low and kidney damage does not occur.
  • New MRI systems can depict brain function, and in this way detect a stroke at a very early stage.

Risks

  • An undetected metal implant may be affected by the strong magnetic field.
  • MRI is generally avoided in the first 12 weeks of pregnancy. Doctors usually use other methods of imaging, such as ultrasound, on pregnant women unless there is a strong medical reason.

 

 What are the limitations of MRI of the Head?

Bone is better imaged by conventional x-rays, and CT is preferred for patients with severe bleeding. MRI may not always distinguish between tumor tissue and edema fluid, and does not detect calcium when this is present within a tumor. In most cases the exam is safe for patients with metal implants but there are a few exceptions, so patients should inform the technician of an implant prior to the test. The exam must be used cautiously in early pregnancy. MRI often costs more than CT scanning.
 
From OncoLog, October 2004, Vol. 49, No. 10

Treating Head and Neck Cancer Requires Extraordinary Coordination Among Disciplines

by Dawn Chalaire

Drs. Randal S. Weber and Kristen Pytynia
New surgical techniques, along with improved nonsurgical alternatives like combined chemotherapy and radiation therapy, have allowed many more head and neck cancer patients to retain the ability to speak and swallow. Here, Dr. Randal S. Weber (r), chair of the Department of Head and Neck Surgery, is assisted by Dr. Kristen Pytynia.

Treating cancer always necessitates a balance between eradicating the disease and preserving function and appearance, and this equilibrium is particularly precarious in the treatment of head and neck cancer.

As soon as surgeons became technically capable of performing extensive resections of head and neck tumors, they raised the question of whether the benefits of these procedures were worth the price. Many patients were cured of their cancer but left with cosmetic deformities or speech or swallowing impairments. It became clear that combining or replacing surgery with other types of treatment to preserve form and function would require a great deal of coordination among different individuals, departments, and disciplines. And so it was that in the treatment of head and neck tumors, the concept of multidisciplinary care was first conceived and practiced at The University of Texas M. D. Anderson Cancer Center in the late 1960s.

“There was a lot of resistance to multidisciplinary care when it was developed because treatment 30 years ago was very territorial,” said Randal S. Weber, M.D., professor and chair of the Department of Head and Neck Surgery. “The true multidisciplinary team concept really grew out of the need to achieve the two goals in cancer care, which are to maximize survival and preserve or restore form and function.”

Changes wrought by multidisciplinary care

The advent of multidisciplinary care has led to many changes in the treatment of head and neck cancer. For example, tumors of the posterior tongue and tonsil once often necessitated removal of part or all of the tongue, which frequently left patients unable to swallow properly or speak. Now, these tumors can often be treated with radiation therapy alone or in combination with chemotherapy.

In disease sites where surgery is still the principal treatment approach, new techniques may allow surgeons to limit the amount of tissue they remove. For example, laser surgery can now be performed on patients with cancers of the larynx to avoid a tracheostomy and permanent loss of the voice.

However, conventional surgery is still required to treat some very advanced cancers, or those of the skin, thyroid, salivary glands, and front part of the tongue, because other treatment modalities for these cancers are not as effective. “So we’re left with the problem that surgery may still create cosmetic and functional loss,” Dr. Weber said.

To minimize and restore the deficits created by surgery, head and neck surgeons consult with plastic surgeons to plan combined extirpative and complex reconstructive procedures using the patient’s own soft tissues and bone, which are harvested with blood vessels from a variety of donor sites in the body and attached to blood vessels and other tissues in the head and neck region.

In some cases, when immediate reconstruction is not feasible or desirable, resected facial structures such as the nose or an ear are replaced with prosthetics created in the Department of Head and Neck Surgery’s Section of Oncologic Dentistry and Prosthodontics. Researchers in the Department of Plastic Surgery are also investigating the use of engineered tissue that can grow and differentiate around a scaffold to replace missing structures.

Pros and cons of chemotherapy and radiation therapy

Treating head and neck tumors with chemotherapy, radiation therapy, or both has enabled physicians to leave certain organs and structures intact, but organ preservation often comes at a significant cost—acute toxic effects that can create scar tissue and damage nerves, adversely affecting the function of the tongue and the larynx.

“What we’ve done over the past decade is intensify radiation therapy using a twofold approach. One approach is to deliver hyperfractionation, or more than one radiation treatment a day. The other approach we’ve taken is adding radiotherapy sensitizers to the treatment regimen, and that is where chemotherapy comes in. Chemotherapy enhances the effect of radiation, but the downside is that it is toxic. So we are preserving organs, but some of those organs don’t function so well because of the toxic effects,” Dr. Weber said.

In a recent study led by Moshe Maor, M.D., a professor in the Department of Radiation Oncology at M. D. Anderson, investigators found that patients with laryngeal cancer who were treated with radiation therapy and chemotherapy concurrently were less likely to require surgical removal of the voice box within two years after treatment than were patients treated with chemotherapy followed by radiation therapy or radiation therapy alone.

Photo: Dr. Lawrence Ginsberg
Dr. Lawrence Ginsberg, a professor in the Department of Diagnostic Radiology, presents to colleagues at a weekly multidisciplinary head and neck cancer seminar.

Radiation therapy and chemotherapy can also be used after surgery to improve local-regional control and survival in patients with advanced head and neck tumors. In the May 6, 2004, issue of the New England Journal of Medicine, similar results were reported from two randomized clinical trials comparing concurrent chemotherapy and radiation therapy versus radiation therapy alone in postoperative patients with advanced head and neck cancer. In both studies, disease-free survival was longer in the patients who received concurrent therapy; however, patients treated with both radiation therapy and chemotherapy were much more likely to have moderate to severe side effects such as nausea, vomiting, pain, and difficulty swallowing.

Even patients treated with radiation therapy alone may suffer from long-term effects, especially a decrease in saliva production. Besides causing discomfort and making it more difficult to speak and swallow, a decrease in saliva can make the teeth more susceptible to cavities, necessitating long-term prophylaxis, including daily fluoride treatments.

To avoid damaging the salivary glands during radiation therapy, different approaches are under investigation. Intensity-modulated radiation therapy is used to focus the treatment beams on the tumor with less damage to surrounding tissues, such as the salivary glands, than that caused by conventional radiation therapy delivery methods.

Follow-up care of patients treated for head and neck cancer

Patients who have been treated for cancers of the head and neck require frequent and extensive follow-up after treatment. Patients with a history of smoking or alcohol abuse are at high risk for a second primary tumor, including lung cancer, esophageal cancer, or another tumor in the head and neck region, and should be referred to alcohol and tobacco cessation programs during treatment recovery.

After treatment, many patients are referred to swallowing therapists, who, among other things, perform tests to assess swallowing function, prescribe exercises to facilitate swallowing, and refer patients to clinical nutritionists for recommendations to develop a balanced diet of foods that the patient is able to swallow.

Head and neck cancer is particularly cruel because the tumor and its treatment can affect two elements that are critical for human interactions—the face and the voice. Speech therapists improve or maintain the patients’ ability to speak through exercises and voice conservation techniques. For patients who receive a voice prosthesis following loss of the larynx, the therapists can help them become acclimated to the device and show them how to use it properly.

In addition to educating patients about oral hygiene and fluoride prophylaxis after radiation therapy, dental oncologists make adjustments to facial prostheses as needed owing to tissue changes and scar contractures.

New treatment approaches on the horizon

Dr. Weber predicts that in the future, the war on head and neck cancer will be waged on several fronts: identifying patients’ genetic risk for developing head and neck cancer and thus selecting them for intensive cancer screening, lifestyle intervention, and drug therapy that may reverse the progression to malignancy; selecting treatment modalities based on the genetic profile of a patient’s tumor; and developing more effective, less toxic treatment combinations.

Erich Sturgis, M.D., an assistant professor in the departments of Head and Neck Surgery and Epidemiology, and his colleagues are attempting to identify genetic profiles that increase the risk of thyroid, salivary, and squamous cell cancers of the head and neck.

In a case-control study, Dr. Sturgis and his colleagues demonstrated that exposure to human papillomavirus type 16 (HPV-16) is the primary risk factor for oropharyngeal cancers in individuals who have never smoked. They also showed that this risk is heightened by a mutation in the p53 tumor suppressor gene. However, in contrast to previous studies, they found no evidence that HPV-16 exposure decreased survival duration.

Mutations in the p53 gene are implicated in many types of cancer, and gene therapy involving the adenoviral vector–mediated delivery of the wild-type p53 gene is being studied in head and neck cancer. Gary Clayman, M.D., a professor in the Department of Head and Neck Surgery, is actively investigating intratumoral administration of the normal p53 gene in patients with squamous cell carcinoma of the head and neck.

To improve treatment efficacy while limiting toxicity, biologic agents such as proteins, antibodies, and small molecules are being added to chemotherapy or radiation therapy. In a study led by investigators at the University of Alabama at Birmingham and M. D. Anderson and presented at the American Society of Clinical Oncology annual meeting in June 2004, adding the epidermal growth factor receptor (EGFR) inhibitor cetuximab to radiation therapy was shown to significantly increase survival duration without increasing toxicity in patients with localized head and neck cancer. In addition to EGFR inhibitors, researchers are conducting clinical trials of treatment combinations with antiangiogenic agents.

“These targeted agents can attack pathways specific to cancer cells, which may permit other treatments used in combination to be more effective in eradicating a cancer cell,” said Dr. Weber. “We are making definite progress towards our dual goals of eradicating head and neck cancer while at the same time preserving form and function.”

UFSCC Cancer more likely to recur in blacks treated for head and neck cancer

Melanie Fridl Ross
Dec. 18, 2003

GAINESVILLE, Fla. — Black people treated for head and neck cancer have double the risk of cancer recurring elsewhere in the body and thus are far more likely to die within five years than white patients who received essentially the same treatment for the same type of malignancies, University of Florida researchers have found.

The discovery adds to a growing body of scientific discoveries that link race with outcomes for various cancers and draws attention to the need for better identification of patients most at risk and for customized therapies, said Dr. William M. Mendenhall, a professor of radiation oncology at UF’s College of Medicine and a member of the UF Shands Cancer Center. UF researchers reported their findings in the Dec. 1 issue of Cancer, the journal of the American Cancer Society.

In the United States, about 37,000 people are diagnosed as having head and neck cancer each year, a figure that represents about 3 percent of all cancer cases. The cancer is most common in people who use tobacco or are heavy drinkers, but it can occur in individuals who have no such risk factors.

“The cure rates are fairly high if you catch it early, so early diagnosis is important,” Mendenhall said. “Another issue is quality of life because of the location of the cancer itself and the treatment of the cancer. If you don’t control this type of cancer it is typically associated with significant detrimental effects on quality of life: It affects your ability to eat, to communicate, to go out in public. It’s not a real common cancer, but it has a major impact on the people who wind up getting it.”

Initially, Mendenhall said he didn’t expect to see any differences in long-term survival in black versus white patients, because the nearly 700 patients whose medical records UF scientists studied all had tumors that were of similar size and aggressiveness. In addition, all patients received identical treatment: twice-daily radiation therapy for six-and-a-half weeks at Shands at UF medical center, and surgery when needed. About 8 percent were black.

Researchers tracked patients for up to seven years and found that cancer was indeed more likely to resurface

in black people, and it usually did so in distant parts of the body, such as the lung, bone or liver.

“I really didn’t think that if you looked at patients with similar stage tumors who were treated the same way that there

would be a difference in outcome,” Mendenhall said. “But all received the exact same treatment and we accounted for confounding variables, like perhaps minority patients might be of lower socioeconomic status and therefore have less access to health care or be less likely to complete treatment or even get the treatment considered to be optimal. I fully expected to see no difference in outcomes. Lo and behold, when we looked there turned out to be a difference. It’s not really clear exactly why.

“The reason it’s important is it tells us we need to do something to modify treatment for those patients to try to reduce their risk of having distant metastasis,” he added. “Because if you develop a distant metastasis, the odds are almost 100 percent you’re going to die from the cancer. So it’s important to try to reduce that risk.”

Other studies have shown that adding chemotherapy to the treatment regimen may help reduce the risk of distant metastases, but additional research will have to be conducted to confirm its effectiveness in blacks,

Mendenhall said.

Researchers also will aim to carefully look at the site and extent of the initial tumor to see whether those factors are linked with the ability to successfully treat cancer recurrence, he said.

“The recurrences we’re seeing in blacks versus whites tend to be distant recurrences,” Mendenhall said. “So the chances of salvaging them from distant metastases is very, very low. Really what we would want to do is modify treatments on the front end rather than keep a closer eye on them afterward.”

UF scientists conceded that a drawback of the study was their inability to access reliable information related to study participants’ lifestyles, including tobacco and alcohol use. Similarly, they did not account for potentially important differences in patients’ health before treatment was begun.

Even so, “our data underscore practical implications that are worth consideration,” the authors wrote in the journal.

Mendenhall emphasized that the study calls attention to the importance of evaluating ethnic and racial influences on disease and prognosis, and he recalled the recent defeat of Proposition 54 in California, which sought to remove references to race in medical records and on a variety of state forms.

“From the medical standpoint, it’s important not to eliminate that information because there may be groups of people, sometimes ethnic groups or racial groups, where the outcome of treatment might be different for that group of patients,” he said. “If you can’t take a look at outcomes and account for race, which you could not do if it was removed from medical records, you wouldn’t know that and you’d lose the opportunity to optimize treatment for these patients.”

Government funding for follow-up studies is crucial to better define and to determine the causes of differences in survival after treatment for head and neck cancer, said Dr. Randal S. Weber, chairman of the department of head and neck surgery at the University of Texas M.D. Anderson Cancer Center.

“This study points out the importance of considering racial differences when evaluating the effectiveness of cancer treatment,” Weber said. “We have known for some time that African-American males with other types of cancers do not do as well as Caucasian males with similar types and stage of cancer. Many factors, such as more advanced cancer stage at presentation and diminished cancer immunity in these patients, may be responsible and will require further study. Dr. Mendenhall's study may help identify patients at higher risk for cancer spread who may benefit from more intensive therapy.”
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