Head & Neck Cancers
Neck Node Metasteses / Mouth or Oral Cavity Cancers / Oropharynx Cancers / Supraglottic Larynx Cancers / Vocal Cord Cancers / Nasal Cavity & Paranasal Sinus Cancers / Nasopharynx Cancers / Nasal Vestibule Cancers / Paragangliomas / Unknown Primary Cancers
The two major modalities for treating head and neck cancer are radiation therapy and surgery. The treatment of choice depends on the site, extent, and cell type (histology) of the cancer. Most cancers of the head and neck region are squamous cell carcinomas.
In general, early-stage cancers are best treated by one modality (either surgery or radiation therapy) rather than a combination of the two treatments. In contrast, patients with more advanced cancers are often best treated with a combination of radiation and surgery, sometimes combined with adjuvant chemotherapy. Patients who would benefit from combined-modality treatment are usually treated with surgery followed by postoperative radiation therapy if the cancer is completely removable by an operation. If not, radiation is given initially to try to cause tumor regression to facilitate complete removal of the malignancy.
Usually, cases of head and neck cancer are presented to the Head and Neck Tumor Board, and the patient is examined by several head and neck cancer specialists. A treatment plan is recommended jointly by the Board. Before any treatment is started, the recommended treatment, the reasons it is recommended, the procedures to be carried out, the expected or possible side effects or complications, and the expected benefits are all explained to the patient and family. The patient must give permission for treatment, based on this knowledge (“informed consent”), before treatment is given.
Following are some general guidelines for treatment of head and neck cancers according to specific tumor site. In general, the chance of cure is in the range of 90% or better for patients with stage I disease, approximately 80% for those with stage II disease, 60% to 70% for those with stage III disease, and 40% to 50% for patients with stage IV cancers.
Management of Neck Node Metasteses / Back to top
Head and neck cancers frequently spread to lymph nodes in the neck. The treatment of the neck nodes is determined in conjunction with the treatment of the primary cancer in the mouth or throat. In general, relatively early stage neck metastasis (small node or nodes that can be removed completely with an operation) are removed in conjunction with the tumor if the first step in treatment is to be an operation. On the other hand, if the primary cancer is best managed with radiation therapy, the neck nodes are treated with irradiation as well, and if they resolve completely at the end of treatment, surgery is not necessary. On the other hand, if neck nodes remain at the end of radiation therapy, it is safest to proceed with an operation to remove them. This operation is referred to as a neck dissection. Large lymph nodes, particularly those that do not go away completely after radiation therapy, are best treated with a combination of radiation and a neck dissection. A computed tomography (CT) or PET-CT scan is used following radiation therapy to determine the probability of remaining cancer and the need for surgery.
Management of Mouth or Oral Cavity Cancers / Back to top
Early-stage carcinomas of the oral cavity are usually treated with an operation. Postoperative radiation therapy is given for indications such as close margins, extracapsular extension of the cancer in lymph nodes, perineural invasion, vascular space invasion, and multiple lymph nodes involved with cancer. Patients with advanced oral cavity cancers are usually treated with surgery followed by postoperative radiation therapy.
Management of Oropharynx Cancers / Back to top
Carcinomas arising in the oropharynx, which includes the tonsils, base (that is, the posterior two thirds) of the tongue, and soft palate, are usually treated with primary radiation therapy. Patients with advanced neck disease (two or more lymph nodes 2 to 3 cm or larger in size) sometimes undergo a neck dissection (removal of the lymph nodes in the neck) after the radiation therapy. Although the primary cancer in the oropharynx may be removed surgically, there is no evidence that this improves the chance of cure, and it is associated with a higher risk for complications. High risk human papilloma virus (HR-HPV) positive oropharyngeal cancers are increasing in frequency and have an improved prognosis compared with HR-HPV negative cancers.
Management of Supraglottic Larynx Cancers / Back to top
Early cancers of the supraglottic larynx (above the vocal cords) may be treated either with surgery or radiation therapy with a high likelihood of success. Moderately advanced cancers are usually treated with radiation therapy, and very advanced cancers are generally treated with surgery followed by radiation therapy. Unfortunately, surgery often involves removal of the larynx (voice box). The volume of the tumor calculated on CT scan or MR images before treatment is related to the chance of successful treatment with radiation therapy, and thus, currently, radiographic volume is used to determine treatment at the University of Florida. Patients who have higher volume lesions who would like to avoid laryngectomy are treated with radiation therapy and concomitant cisplatin chemotherapy. CT scan may also be used to follow up patients after treatment to detect early recurrences and facilitate successful surgical salvage.
Management of Vocal Cord Cancers / Back to top
Some patients with early cancers involving part of one vocal cord are suitable for CO2 laser resection with a good outcome. The remaining patients with early carcinomas of the vocal cords (T1 or T2) are generally treated with radiation therapy. The chance of cure is essentially the same as it would be after conservative surgery, and voice quality is better. Advanced laryngeal cancers are treated with radiation therapy alone for smaller volume tumors, “chemoradiation” (a combination of chemotherapy and radiation therapy) for larger volume tumors, and total laryngectomy plus postoperative radiation therapy for patients with very advanced disease.
Management of Nasal Cavity and Paranasal Sinus Cancers / Back to top
The treatment for cancer arising in the nasal cavity and paranasal sinuses is either radiation therapy alone or a combination of surgery combined with adjuvant radiation therapy. The chance of cure is inversely related to the extent of the primary tumor (whether the cancer arises in the nasal cavity or sinuses). The chance of spread to distant sites of the body and/or lymph nodes in the neck is relatively low. The cure rates after radiation therapy alone or a combination of irradiation and surgery are similar. However, by combining surgery with irradiation, it is possible to use a lower radiation dose, thus lowering the risk of complications such as damage to the optic nerves and brain. Proton beam irradiation is often considered to reduce the dose to the brain, eyes, and optic nerves and further reduce the risk of complications.
Management of Nasopharynx Cancers / Back to top
Cancers of the nasopharynx are relatively uncommon in the United States. The optimal treatment of nasopharyngeal cancer is radiation therapy, often combined with chemotherapy for patients with advanced tumors.
Management of Nasal Vestibule Cancers / Back to top
Cancers arising in the nasal vestibule, just inside the opening of the nose, are relatively uncommon and are usually squamous cell carcinomas. They tend to behave like skin cancers and can be treated either with surgery or radiation therapy. The disadvantage of surgery for all but the earliest tumors is that the cosmetic result may be suboptimal, depending on how much of the nose must be removed, and a complex reconstructive procedure may be required. Radiation therapy alone is used to treat most of these cancers and usually consists of a combination of external beam irradiation and interstitial brachytherapy boosts. The chance of cure is essentially the same after either surgery or radiation therapy for all but the most advanced cancers. Very advanced cancers, which are more than 4 cm in diameter and invade bone, are probably best treated with a combination of surgery and radiation therapy because the chance of cure with radiation therapy alone in this instance is fairly low.
Management of Paragangliomas / Back to top
Paragangliomas usually arise in the temporal bone near the ear. Less commonly, they arise adjacent to the carotid artery in the neck. The treatment of choice for smaller tumors that are removable with minimal morbidity is surgery. On the other hand, if the tumor is advanced and surgery would result in a significant risk of complications and possibly permanent neurologic deficits, such as sacrifice of some of the cranial nerves, the treatment of choice is radiation therapy. Radiation therapy usually consists of 5 weeks of treatment given once a day to a moderate dose. The chance of cure with radiation therapy is 90% or higher.
Management of Unknown Primary Cancers / Back to top
A small proportion of patients with head and neck cancer have a malignancy that has metastasized to a lymph node in the neck from an unknown “primary site” in the mouth or throat. Following a search for the origin of the cancer (primary site) with a physical exam and CT scan, biopsy of suspected primary sites are obtained under anesthesia. The primary cancer site can be found in about 50% of patients and is most likely in the tonsil or base of tongue. Treatment usually consists of radiation either alone, or combined with an operation to remove the malignant lymph nodes in the neck. Detection of the primary site will influence the areas included in the radiation fields and the “fractionation schedule,” (whether the treatment is given once or twice a day). Even if the primary site is not found, the chance of cure is relatively high.