Head and neck cancers: symptoms, diagnosis and treatment

By Cristiano Antonino On Dec 7, 2022

Head and neck cancers, also called head and neck tumours, include very different tumours that originate in the organs and structures of the head and neck area, including the upper aerodigestive tract

Overall, head and neck cancers account for about 10-12% of all malignant tumours in men and 4-5% in women

Overall, in Italy, according to AIRTUM 2020 estimates, there are 9,900 diagnoses, of which 7,300 males and 2,600 females, with a 5-year survival after diagnosis of 57% in males and 58% in females.

The prognosis varies greatly depending on the stage of the disease and in particular the involvement of lymph nodes, the appearance or absence of loco-regional or distant recurrences after initial treatment.

These tumours represent a major clinical and social problem because of the delicate organ functions they can impair.

The known risk factors underlying most head and neck cancers are smoking, alcohol and certain viruses.

What are head and neck cancers?

Head and neck cancers include:

tumours of the oral cavity (lips, tongue, oral floor, gum mucosa, palate)
tumours of the pharynx (nasopharynx, oropharynx and hypopharynx)
tumours of the larynx
tumours of the nasal cavities and paranasal sinuses
tumours of the salivary glands (parotid, submandibular, sublingual and minor salivary glands)
thyroid and parathyroid gland tumours
tumours of the lymph nodes of the neck
tumours of the skin of the head and neck
tumours of the ear and temporal bone
tumours of the eye orbit
tumours of the base of the skull.

What are the risk factors for head and neck cancers?

Of the known risk factors for head and neck cancers, cigarette smoking and alcohol consumption are, in general, the main culprits.

Other risk factors are also recognised for some of these tumours, such as:

poor oral hygiene
poor consumption of vegetables and fruit
exposure to certain substances (as in the case of sinus tumours, which have a higher incidence in those who work with wood, such as carpenters and parquetry workers)
viral infections with Epstein Barr Virus (EBV) or Human Papilloma Virus (HPV) (considered among the causes of some forms of head and neck cancers).

What are the symptoms of head and neck cancers?

Head and neck cancers manifest themselves with different symptoms depending on the area affected.

In general, symptoms such as:

burning or pain in the mouth, in association with ulcerations or neoformations, sometimes bleeding, that have difficulty healing
lowering of the voice (dysphonia) that persists for more than two to three weeks
difficulty breathing or a feeling of ‘bulkiness’ in the throat
pain or difficulty swallowing with radiation to one ear
swelling of the neck in the lateral (lymph node disease) or anterior (thyroid gland) regions
nosebleeds with respiratory obstruction or intense headaches.

How are head and neck tumours diagnosed?

The diagnosis of head and neck tumours is based on the clinical assessment of the symptoms reported by the patient and the collection of his or her clinical history (anamnesis), together with radiological instrumental examinations (to assess any local, regional or distant spread of the tumour, so that the right therapeutic planning can be made) and endoscopic examinations.

These are fundamental examinations for the diagnosis of head and neck tumours:

Endoscopy: is performed with a rigid or flexible endoscope with a camera connected to a monitor or recording systems that allows us to see any lesions.
Biopsy: allows the type of tumour and its biological aggressiveness to be ascertained, thanks to histological analysis of a tissue sample taken under local or general anaesthesia. In the case of enlargement of lateral portions or the anterior region of the neck, needle biopsy is performed, i.e. a biopsy guided by ultrasound examination using a needle slightly larger than a syringe that sucks the cells to be examined through the skin.
Ultrasound: this is a diagnostic imaging method that uses ultrasound and does not use ionising radiation. It is used for the correct diagnosis of pathological lymph nodes and for the evaluation of salivary gland and thyroid gland tumours.
Magnetic resonance imaging (MRI): provides detailed images of the region to be studied using magnetic fields, without exposing the patient to ionising radiation. It is the most suitable examination for defining the extent of the tumour and its relationship with neighbouring structures, as well as for reassessing patients after treatment. Intravenous administration of contrast medium may be required: the most common is gadolinium.
Computed Axial Tomography (CT): is an X-ray examination using ionising radiation. To obtain more information on the vascularisation of organs and tissues, an iodine-based contrast agent is used, injected intravenously. It is a valid alternative to Nuclear Magnetic Resonance Imaging in staging the disease and can be complementary to it for studying the involvement of bone structures and to exclude the presence of distant pulmonary or encephalic localisations.
Positron Emission Tomography (PET) with 18-fluorodeoxyglucose (FDG): this is an examination involving intravenous administration of glucose labelled with a radioactive molecule (Fluorine 18) that accumulates in glucose-hungry tumours. The PET scan detects the accumulation of 18-FDG, allowing highly accurate identification of the site of disease, involvement of locoregional lymph nodes and distant localisations in staging. It is useful in post-treatment follow-up to detect any recurrence.
Blood tests: they are diagnostically essential only in cases of thyroid gland and parathyroid gland pathology, for calcitonin (a key hormone for diagnosing medullary thyroid carcinoma) and parathormone assays, performed during and after surgery to remove parathyroid adenomas, as it is an evaluation value for therapeutic success.

What are the treatments for head and neck tumours?

The choice of treatments for tumours of the head and neck depends on the type of tumour, the location, the stage of the disease and the general condition or will of the patient.

The treatment of these tumours involves, in addition to surgery and medical treatment, a protocol of medical, instrumental and laboratory checks, at variable but regular intervals, to intercept early and anticipate any local, regional or distant disease relapse (recurrence).

Sometimes, therapy may also include speech therapy rehabilitation support for the resumption of phonation and swallowing.

Surgery is very often the treatment of first choice for head and neck tumours

Today, thanks to new technologies and better knowledge of tumour biology, the patient obtains valid oncological results with minimally invasive surgery, including laser and robotic surgery, which has made it possible to perform much more conservative operations than in the past.

Moreover, the minimally invasive approach allows surgery without skin incisions, with a shorter hospital stay and convalescence time, and a faster resumption of normal daily habits and activities.

In particular, transoral laser surgery makes it possible to treat diseases of the mouth, pharynx, and especially the larynx, while small and medium-sized tumours can be removed without neck incisions, and thanks to the use of an operating microscope or exoscope, can be removed while minimising functional damage.

In cases where minimally invasive or robotic surgical techniques are not feasible, traditional procedures carried out in such a way as to avoid massive demolition and functional damage remain current.

Malignant tumours of the larynx, for example, are nowadays more often treatable with surgical methods and conservative techniques than with traditional en bloc removal of the voice organ.

In cases where, even today, removal of the phonatory organ is unavoidable, technology provides the possibility of applying prostheses to replace the vocal cords.

Reconstructive surgery

Surgical treatment of head and neck tumours must take into account not only the radical removal of the disease, but also the aesthetic and functional conservative aspect.

Reconstructive surgery, in addition to reconstructing skin, mucous, muscle or bone tissue, guarantees an improvement in the chances of resuming swallowing and breathing functions.

Reconstruction can take place through the use of local, regional or remote flaps.

In the latter case, the use of flaps defined as ‘free’ involves the use of the microscope or exoscope for the packing of microvascular anastomoses.

The Operative Unit of Otolaryngology uses 3D printing technology for preoperative ablative and reconstructive planning in collaboration with the Clinical Engineering Unit.

The techniques used also allow the preservation of important functional aspects inherent to the nerve component, such as in salivary gland and temporal bone tumours (facial nerve), thyroid tumours (inferior or recurrent laryngeal nerve).

In such cases, using intraoperative monitoring systems of the activity of these cranial nerves can preserve their function.

Radiotherapy

Radiotherapy is one of the main therapeutic treatments of tumours in the head and neck region.

Thanks to new techniques such as intensity-modulated and digital image-guided radiotherapy (IMRT/IGRT), modern radiotherapy allows high doses of radiation to be targeted only at the tumour mass, thus minimising the expected side effects of healthy organs close to the tumour.

Alone, as the first treatment of choice, radiation therapy with curative intent is frequently indicated in nasopharyngeal tumours or in the treatment of early-stage laryngeal cancer, as a non-invasive alternative to surgery.

As an exclusive treatment, radiotherapy may also be indicated to reduce symptoms or the consequences of local disease progression in order to improve the patient’s quality of life.

Radiotherapy, in combination with chemotherapy, may be an alternative treatment option in cases where only demolitive surgery is technically possible due to the locoregional extension of the disease: in these cases, radiotherapy aims to preserve the organ.

Post-operative radiotherapy prescribed within a few months after surgery, is indicated when complete surgical eradication of the tumour has not been possible, due to the presence of residual disease or risk factors for local recurrence.

Conversely, radiotherapy even long after surgery is indicated in cases where local recurrence of disease is present: in these cases, one speaks of salvage radiotherapy.

In selected cases of patients often already receiving standard radiotherapy, targeted treatment with millimetre precision can be given to small tumours of the head and neck, thanks to radiosurgery, a radiotherapy technique carried out in a few sessions (3-5).

Chemotherapy

Chemotherapy in head and neck tumours may be indicated in advanced disease to reduce the volume of the tumour mass prior to removal surgery; in combination with radiotherapy, chemotherapy may be indicated as an alternative to very disabling and demolitive surgery, in the case of very large tumours, or as the treatment of first choice in small tumours of the nasopharynx and palatine tonsils.

Chemotherapy is also used for the control of metastatic tumours.

A further therapeutic option is provided by biologic drugs active against certain tumour growth factors, which make it possible to reduce the toxicity of chemotherapy and to extend treatment to more advanced age groups that were previously impractical.

Follow-up

After treatment of head and neck cancer, regular check-ups are necessary to ensure that the tumour does not recur or that a second (new) primary tumour does not develop.

Depending on the type of cancer, medical check-ups may include specialist ENT, oncology and radiotherapy examinations and radiological examinations (CT, MRI, PET). It may be necessary to assess thyroid and pituitary function after radiotherapy treatment.

In addition, in the case of smokers, the doctor will advise patients to stop smoking.

Research has shown that continued smoking by a patient with head and neck cancer may reduce the effectiveness of treatment and increase the possibility of a second primary tumour (lung, cervical oesophagus).

In HPV+ tumours, screening for HPV-related tumours of the ano-genital region may be useful.

From diagnosis until the end of treatment, patients receive most medical care from surgery and radiation oncology specialists).

Once the treatment is finished, they are referred to the general practitioner.

Once the treatment has ended, the patient will be informed about the frequency of check-ups and symptoms to watch out for that are suggestive of recurrence or treatment toxicity.

It is necessary to inform one’s doctor about the treatment received and to book examinations and radiological examinations in accordance with the procedures and timeframes set out in one’s treatment plan.

Survival

Survival from head and neck cancers focuses on health and psycho-physical and socio-economic problems after completion of primary cancer treatment.

Cancer survivors after primary treatment include disease-free patients after completion of treatment, persons undergoing treatment to reduce the risk of cancer recurrence, and persons with well-controlled disease who are undergoing treatment.

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