Head & Neck Cancer

Robert Miller MD

www.aboutcancer.com

1. Cause, the symptoms and the anatomy

2. Histology: most common is squamous cancer

3. Imaging: CT and PET scans

4. Stage is based on the size of the tumor and the number or size of lymph nodes

Head and Neck Cancer

Risk Factors Associated with Oral Cancer

1.Tobacco Use (5 to 25X)2. Alcohol (heavy drinkers double

their risk)3.Oral infection with HPV164.Sun exposure for lip cancer5.Reflux - ? Larynx cancer

The cure rate is better for HPV cancers than for smoking related cancers

JCO June 10, 2012 vol. 30 no. 17 2102-2111

Non-smokers

smokers

SURVIVAL

Years

Cure Rates are better for people who stop smoking during the radiation

JCO June 10, 2012 vol. 30 no. 17 2102-2111

Years

Most Common Head and Neck Cancers

Pharynx13,930

Tongue13,590

Larynx12,260

Mouth11,400

Other oral 2,460

2013 data (note that same year there were 228,190 lung cancers and 234,580 breast cancers)

Lifetime Risk of Getting Cancer

Site Men Women

Any Cancer 44% 37%

Oral/Pharynx

1.39% 0.65%

Larynx 0.61% 0.14%

Median Age for Oral/Pharynx is 62y in 2005-2009

20 35 45 55 65 75 850

5

10

15

20

25

30

Age

Median Age for Larynx Cancer is 65y in 2005-2009

20 35 45 55 65 75 850

5

10

15

20

25

30

Age

Stage and Survival 2002-2008Oral Cavity and Pharynx

Stage Distribution

Survival (5y)

All 100% 61.5%

Local 32% 82.4%

Regional 47% 57.3%

Distant 16% 34.9%

Stage and Survival 2002-2008Larynx Cancer

Stage Distribution

Survival (5y)

All 100% 60.5%

Local 57% 76.4%

Regional 20% 41.8%

Distant 18% 34.8%

Oral Cavity

Oral Cavity Cancer• Present with a sore in the mouth that

does not heal• Commonly in the oral tongue, the floor

of the mouth or the inside of the cheek (buccal mucosa)

• Sometimes present with a swollen lymph node in the neck

Cross Section Anatomy

CT Scan and Anatomy

CT-PET Anatomysmall cancer in the front of the tongue (oral tongue)

Oral Cavity Stage: T (tumor)

Tumor Size

T1 2cm

T2 > 2 to 4cm

T3 > 4cm

T4 Deeply invasive

Oral Cavity Stage: N (nodes)

Nodes Site

N1 Single node up to 3cm

N2a Node >3 to 6cm

N2b Multiple ipsilateral

N2c Contralateral

N3 Node > 6cm

Oral Cavity Stage

Stage Definition

Stage 1 T1N0

Stage 2 T2N0

Stage 3 T3 or N1

Stage 4A T4a or N2

Stage 4B T4b or N3

Stage 4C Metastases

Anatomy of the Pharynx

Cancer of the Nasopharynx

Uncommon cancer in the US, related to EBV (Epstein-Barr virus). Located high in the back of the throat

Symptoms: include nasal congestion, hearing problems (fluid behind the ear drums)

Late symptoms: if the cancer invade the skull can be cranial nerve problems or headaches

Other late symptoms include lymph node swelling

Cancer of the Oropharynx

Most common sites include the tonsil and the base of the tongue

May be related to HPV virus (so more common in non smokers)

Symptoms include sore throat with pain radiating into the ear, trouble swallowing and lymph node enlargement

mandible normal tongue

throat (pharynx)

spinespinal cord

salivarygland normal

lymph nodes

Cancer in Base of Tongue

Squamous Cancer Right Tonsil – Very Visible on PET scan

Oropharynx Stage: T (tumor)

Tumor Size

T1 2 cm

T2 >2 to 4cm

T3 > 4cm

T4 Deeply Invasive

Oropharynx Stage: N (nodes)

Node Size

N1 Single node up to 3cm

N2a Node >3 to 6cm

N2b Multiple Ipsilateral

N2c Contralateral Nodes

N3 Node >6 cm

Oropharynx Stage

Stage Definition

Stage 1 T1N0

Stage 2 T2N0

Stage 3 T3 or N1

Stage 4A T4a or N2

Stage 4B T4b or N3

Stage 4C Metastases

PET CT Anatomy for Tonsil Cancer, Stage IVa with multiple

involved nodes (N2)

Cancer of the Hypopharynx

Less common

Low in the throat, most common site is in the pyriform sinus

Symptoms are usually trouble swallowing or hoarseness

Other late symptoms include lymph node swelling

Lymph Nodes

Neck Node Levels

PET Scan showing Multiple Level Lymph Node Spread

PET Scans are Very Good Showing Lymph Node Spread

Larynx Anatomy

Larynx Cancer

If supraglottic larynx is commonly involves the epiglottis and symptoms include sore throat and trouble swallowing

If the true vocal cords the symptoms are almost always hoarse voice

Late stage symptoms include lymph node swelling in the neck and weight loss

Common site for larynx cancer is the spot where the two vocal cords come together in the front of the larynx (called the anterior commissure)

Larynx Stage: T (tumor)

Tumor Size

T1 One site

T2 Two sites/ impaired mobility

T3 Paralyzed cord

T4 Deeply Invasive

Larynx Stage: N (nodes)

Node Size

N1 Single node up to 3cm

N2a Node >3 to 6cm

N2b Multiple Ipsilateral

N2c Contralateral Nodes

N3 Node >6 cm

Larynx Stage

Stage Definition

Stage 1 T1N0

Stage 2 T2N0

Stage 3 T3 or N1

Stage 4A T4a or N2

Stage 4B T4b or N3

Stage 4C Metastases

NCCN.org

Increasing Complexity in the Management of Head & Neck Cancer

Treatment options for head and neck cancer

Early stages: surgery or radiation

Advanced stage: surgery followed by radiation and chemotherapy or chemoradiation alone

Very advanced cases: radiation and chemotherapy

Treatment decisions and management should be made by

a team of physicians

• Experienced cancer Surgeon and reconstruction team

• Radiation oncologist with access to state of the art equipment (IGRT or Tomotherapy)

• Medical Oncologist (chemotherapy and targeted therapy)

• Support personnel including nutritional support and dental care

Multidisciplinary Team

Support Team

Head & Neck Cancer

Robert Miller MD

www.aboutcancer.com