Dental exam: Your dentist will probably do a complete exam and maybe some x-rays of your teeth and jaw before any radiation is given because radiation can damage the saliva spit glands and cause dry mouth. The dentist might also remove bad teeth to lower the chances of cavities and infection. Hearing test: The most common chemo drug used to treat oral cavity and oropharyngeal cancer, cisplatin, can cause ringing in the ears or even hearing loss.
You might have your hearing checked with an audiogram before starting treatment and your chemotherapy might be changed if your hearing is poor to start with. Nutrition and speech tests: A nutritionist might check your nutrition status before, during, and after treatment to try and keep your body weight and protein levels as normal as possible.
A speech therapist might test how well you swallow and speak. They might give you exercises to do to help strengthen the muscles so that you can eat and talk normally after finishing treatment.
Blood tests: Blood tests are not used to find cancer of the oral cavity or oropharynx, but they can tell the doctor more about your overall health, like your kidney or liver function. Quit smoking: If you smoke cigarettes or use chewing tobacco, your doctor might talk to you about quitting all tobacco products before starting treatment.
Smoking while getting cancer treatment can cause problems such as poor wound healing after surgery, more side effects from chemo, and a higher chance of infection. If you have oral cavity or oropharyngeal cancer, the doctor will want to find out how far it has spread. This is called staging. Knowing the stage will help your doctor decide what type of treatment is best for you.
The stage describes the spread of the cancer in the place it started. It also tells if the cancer has spread to nearby organs or to organs farther away. Your cancer can be stage 0, 1, 2, 3, or 4. The lower the number, the less the cancer has spread. A higher number, like stage 4, means a more serious cancer that has spread from where it started. Be sure to ask the doctor about the cancer stage and what it means for you.
You might get more than one type of treatment. Some of these cancers are in places that are hard to operate on. Still, surgery may be used to take out the cancer and an edge of healthy tissue around it. In some cases, all or part of the tongue, throat, voice box, or jaw bone may need to be removed. Surgery may also be used to take out lymph nodes in the neck that might have cancer. Surgery can also be used to help you do things that the cancer may have changed. Some surgeries can even help rebuild part of the throat.
Any type of surgery can have risks and side effects. Ask the doctor what you can expect. If you have problems, let your doctors know. Doctors who treat people with oral cavity and oropharyngeal cancers should be able to help you with any problems that come up.
Surgery Surgical extirpation of relatively inaccessible tumors in the oropharynx traditionally required radical surgery, including mandibulotomy or mandibulectomy, and, occasionally laryngectomy. These surgical procedures were associated with worse functional outcomes relative to nonsurgical approaches.
Radical surgery, however, has been supplanted by minimally invasive approaches. Using bivalved laryngoscopes for tumor exposure, surgical resection using the carbon dioxide laser coupled to a microscope has led to complete pathologic resections and high local control rates for oropharyngeal cancer.
The reported functional results have been good, with few patients requiring placement of a feeding tube or tracheotomies. The use of the line-of-sight carbon dioxide CO 2 laser beam has been limited by inadequate exposure of the pathologic lesion in patients with short or stiff necks, retrognathia, full dentition, trismus, or obesity.
Limited access to pathology has precluded use of transoral CO2 laser surgery in many patients. A flexible, photonic, band-gap fiber for the delivery of CO 2 laser energy that was developed by OmniGuide Inc, allows video-assisted visualization and extirpation of previously poorly accessible pathology.
Limited access has also been surmounted by the adaptation of the surgical robot for transoral applications. Improved surgical exposure to tumors in the upper aerodigestive tract have been reported relative to those obtained with more traditional transoral approaches. Minimally invasive surgery is safe and effective for early-stage disease stages I and II , but its role in treating advanced-stage disease has yet to be defined.
The base of the tongue Cancer of the base of the tongue is far less common than that of the oral tongue. Anatomy The base of the tongue is bordered anteriorly by the circumvallate papillae and posteriorly by the epiglottis.
There is a rich lymphatic network, with metastases frequently seen in levels II—V. Natural history The base of the tongue is notorious for lesions that infiltrate deeply into muscle and are advanced at diagnosis. This finding is probably due to the relatively asymptomatic anatomic location.
Thus, bimanual oral examination with digital palpation is a critical part of the physical examination. Most patients present with pain and dysphagia. Other symptoms include a neck mass, weight loss, otalgia, and trismus. All oropharyngeal cancers have a strong propensity to spread to the lymph nodes, and tumors arising at the base of the tongue are no exception.
Treatment Early-stage disease Stage I or II cancers may be treated equally effectively with either surgical resection or radiation therapy alone. If irradiation of the primary tumor is employed, both sides of the neck should be treated, even if the nodes do not seem to be involved. Surgical management of an oropharyngeal malignancy includes lymphadenectomy. For patients clinically staged N0, selective neck dissection encompassing levels II—IV is sufficient.
For patients with cancers at the base of the tongue, bilateral neck dissection is required. Advanced disease More advanced disease may require total resection of the tongue base with or without laryngectomy to ensure complete removal of disease. Total resection of the tongue base is associated with severe oropharyngeal dysphagia with aspiration, but even subtotal resection of the base of the tongue may result in significant aspiration, which is exacerbated by postoperative radiotherapy.
Total laryngectomy may be the only way to isolate the airway from oral secretions and eliminate the risk of aspiration. Chemoradiation therapy via external-beam irradiation or irradiation alone combined with an implant can be curative for patients with advanced tumors of the tongue base. Results In general, the prognosis of cancers of the tongue base is poor due to their advanced stage at presentation. The extent of nodal disease predicts survival. The major determinant of treatment failure is the tumor's growth pattern, with a high local tumor control rate for exophytic lesions and a far worse rate for infiltrative tumors.
Tonsils and tonsillar pillar The tonsils and tonsillar pillar are the most common locations for tumors of the oropharynx. Natural history Tonsillar fossa tumors tend to be more advanced and more frequently metastasize to the neck than do tonsillar pillar cancers.
Symptoms include pain, dysphagia, weight loss, a mass in the neck, and trismus. Treatment Single-modality therapy irradiation or surgery alone is acceptable for T1 and T2 tumors. Irradiation alone may be curative for more advanced tumors, although chemotherapy is often added in a concurrent fashion for T3 or T4 disease or in the setting of N2 or N3 disease.
The neck should always be included in treatment planning. More advanced disease usually requires surgery combined with irradiation. Anatomy The hypopharynx or laryngopharynx is the entrance to the esophagus. The superior aspect above the plane of the hyoid bone communicates with the oropharynx, and the inferior border is situated in the plane of the lowest part of the cricoid cartilage the esophageal inlet.
The anterior surface postcricoid area is contiguous with the posterior surface of the larynx, adjacent to the lamina of the cricoid cartilage. The pharyngeal musculature forms the lateral and posterior walls. The piriform sinuses are within the hypopharynx on each side of the larynx. The hypopharynx contains three subsites: the paired piriform sinuses lateral, pear-shaped funnels ; the posterior pharyngeal wall, from the level of the vallecula to the level of the cricoarytenoid joints; and the postcricoid area pharyngoesophageal junction , which begins just below the arytenoids and extends to the inferior border of the cricoid cartilage.
The piriform sinuses are composed of a medial wall, which abuts the aryepiglottic fold, and a lateral wall. Seventy percent of hypopharyngeal cancers occur in the piriform sinuses.
They may cause a sore throat, otalgia, a change in voice, odynophagia, or an isolated neck mass. Subtle changes on physical examination, including pooling of secretions, should be regarded with concern.
Nodal metastases Diffuse local spread is common and is due to tumor extension within the submucosa. Abundant lymphatic drainage results in a higher incidence of lymph node metastases than with other head and neck tumors. Synchronous lesions These are common. Chemotherapy and external-beam radiotherapy Similar in design to the VA Cooperative Laryngeal Cancer Study, a randomized EORTC trial has shown that initial therapy with cisplatin and 5-FU, followed by definitive irradiation in patients with complete remissions or, alternatively, surgical salvage , results in at least equivalent survival relative to immediate pharyngolaryngectomy.
Though directed to laryngeal cancers rather than hypopharyngeal cancers , the RTOG trial results have been widely interpreted as applying to hypopharyngeal cancer, increasing enthusiasm for concomitant chemoradiation therapy for patients with advanced cancers of the hypopharynx. Transoral laser surgery for piriform sinus carcinoma Organ-sparing approaches such as transoral laser microsurgery for piriform sinus carcinomas have been used in several institutions for the past 25 years.
Long-term follow-up in a retrospective review of previously untreated patients has been published Steiner et al.
Radiation therapy was administered after surgery. Laryngeal preservation rates were comparable to the local tumor control rates. These oncologic and functional results compare favorably with those obtained with either nonsurgical or surgical approaches requiring opening the neck and pharynx. Laryngeal cancers constitute approximately 1. Approximately 12, new cases are expected in , and some 3, will die from the disease.
Anatomy and pathology The laryngeal anatomy is complex and includes cartilages, membranes, and muscles. The three. The TNM staging system for cancers of the larynx is outlined in Table 4. Surgery Surgical treatment for laryngeal cancer includes transoral or open approaches.
Treatment is dictated by the site and extent of the lesion. All or part of the larynx may need to be removed to achieve surgical control of laryngeal cancer. Decision-making for partial laryngectomy is complex and depends on the patient's overall health, the extent of local disease, the skill of the surgeon, and patient preference.
External-beam radiation therapy and chemoradiation therapy With improvements in techniques and fractionation schedules, external-beam radiation therapy, which allows for laryngeal preservation, is an option for all but the most advanced tumors.
Results As in other head and neck sites, patients with early laryngeal cancer may be treated with surgery or radiation therapy, and those with advanced-stage disease require multimodal therapy, including surgery and postoperative radiation therapy or chemotherapy and radiation therapy.
However, transoral laser surgery requires technical expertise limited to a small number of institutions. Select patients with T3 or T4 laryngeal cancers may be candidates for larynx preservation surgery, but most require total laryngectomy as the surgical option. The VA Cooperative Laryngeal Cancer Study was the first trial to test the efficacy of chemotherapy and radiation therapy in the management of stages III and IV laryngeal cancer, assess the possibility for laryngeal preservation using such a regimen, and compare its efficacy against the historic standard of surgery and postoperative radiation therapy.
The VA Cooperative Laryngeal Cancer Study randomized patients with resectable squamous cell carcinoma of the larynx to receive either total laryngectomy followed by radiation therapy or neoadjuvant therapy with cisplatin and 5-FU followed by radiation therapy for those achieving a good response to chemotherapy. Approximately two-thirds of patients survived 2 years following the combination of either chemotherapy plus irradiation or resection plus irradiation.
Of those patients initially treated with chemotherapy and irradiation, one-third required total laryngectomy because of a lack of response to treatment; the larynx was successfully preserved in two-thirds of these patients. In this study, the increased local recurrence rate in the chemoradiation therapy group was offset by the decreased incidence of distant metastases and second primary tumors, and the 2-year survival rate was comparable between the groups.
Advanced T stage was a risk factor for local failure in this study. Data from the RTOG trial demonstrated an improvement in locoregional tumor control using concurrent chemoradiation therapy relative to induction chemotherapy followed by radiotherapy or radiotherapy alone.
There was no primarily surgical or altered fractionated arm in this study. The authors concluded that the combination of irradiation and concurrent cisplatin was superior to induction chemotherapy followed by irradiation or irradiation alone for laryngeal preservation and locoregional tumor control.
Half of patients with T3 cancer are cured, whereas more than two-thirds of patients with T4 cancer will die of the disease. Supraglottic tumors occur less frequently than tumors of the true vocal cords. The epiglottis is the most common location for supraglottic cancers. Natural history Tumors close to the glottis produce symptoms earlier than do tumors at other subsites.
The supraglottis has a rich lymphatic network. The neck is a frequent site of recurrence in patients with supraglottic malignancies. Treatment Appropriate cancers may be treated with partial laryngectomy. Supraglottic laryngectomy removes the upper portion of the thyroid cartilage and its contents, including the false vocal cords, as well as the epiglottis and aryepiglottic folds.
This approach preserves speech and swallowing, but more extensive resections are not well tolerated by patients with impaired lung function who are not able to tolerate the inevitable postoperative aspiration. Supracricoid partial laryngectomy is suitable for supraglottic tumors that cross the ventricle to involve the glottis. Select T3 tumors with limited pre-epiglottic space involvement may be approached with this procedure.
Patients must have sufficient pulmonary reserve to be able to tolerate the chronic aspiration associated with this procedure. Significant technical expertise is needed, and patients must have the proper habitus to assure adequate exposure. Supraglottic laryngectomy is seldom appropriate as salvage therapy following irradiation due to complications, including swelling, difficulty swallowing, and poor wound healing.
The usual salvage operation for persistent supraglottic cancer following radiation therapy is total laryngectomy. However, some patients remain candidates for larynx-preservation surgery. Advanced-stage laryngeal cancer usually requires multinodal treatment, as noted previously. Laryngeal preservation frequently is not possible using primary surgical approaches. The use of primary radiation enables preservation of the larynx. The use of combined radiation concurrently with chemotherapy is the treatment of choice for many patients.
The glottis is the most common location of laryngeal cancer in the United States, comprising more than half of all cases. The incidence of laryngeal cancers and other malignancies related to smoking has been declining. Natural history The cure rate for tumors of the true vocal cords is high. These cancers produce symptoms early, and, thus, most are small when detected. Normal cord mobility implies invasion of disease limited to the submucosa.
Deeper tumor invasion results in impaired vocal cord motion; this finding is most common in the anterior two-thirds of the vocal cord. The true vocal cords have very little lymphatic drainage. Treatment Carcinoma in situ is highly curable and may be treated equally well with microexcision, laser vaporization, or radiation therapy. Treatment decisions should be based up on the extent of local disease.
Serial recurrences should heighten suspicion of an invasive component, and a more aggressive approach, such as partial or total laryngectomy or irradiation, should be employed.
Partial laryngectomy can be performed in selected patients after irradiation failure of some T1—T2 glottic cancers. Advanced T4 disease is best treated with total laryngectomy. Neck involvement worsens the prognosis dramatically. Treatment Partial laryngectomy is not practical for the treatment of tumors in the subglottis, and, thus, therapy usually includes total laryngectomy plus neck dissection. Combination therapy surgery plus radiation therapy [60—65 Gy in 6—7 weeks] is recommended for more advanced disease.
Most failures occur in the neck. The cervical lymph nodes are the most common metastatic site at which squamous cell carcinoma is found. Natural history Most patients who present with squamous cell carcinoma involving cervical lymph nodes, especially in the upper or middle portion of the cervical chain, will have a primary site within the head and neck. When the lower cervical or supraclavicular lymph nodes are involved, a primary lung cancer should be suspected. Esophagoscopy and bronchoscopy seldom yield a diagnosis in patients with upper cervical lymph node involvement.
Treatment A substantial percentage of patients achieve long-term disease-free survival after treatment of the involved side of the neck.
Locoregional control and survival are diminished by multiple lymph nodes and the presence of extracapsular extension of disease in the involved neck.
Irradiation alone Patients with early-stage neck disease N1 disease can be treated with surgery alone if an open biopsy has not been performed. Radiation therapy dosages and techniques should be similar to those used in patients with early-stage ie T1 , primary head and neck cancer. Dosages ranging from 5, to 6, cGy are acceptable. The nasopharynx, and oropharynx, with or without the hypopharynx, should be included in the irradiated field. Irradiation alone or combined with surgery Combination therapy surgery plus radiation therapy [60—65 Gy in 6—7 weeks] is recommended for patients found at surgery to have multiple involved nodes or extracapsular extension or for those who have suspected residual microscopic disease in the neck without a clinically detectable tumor.
Open nodal biopsy does not appear to compromise outcome as long as adequate radiotherapy is delivered subsequently. The volume of tumor in the involved neck influences outcome, with N1 and N2 disease having a significantly higher cure rate than N3 disease or massive neck involvement. Regional relapse is usually predicted by extranodal disease. Chemotherapy The role of chemotherapy in treating patients with an unknown primary metastatic squamous carcinoma in cervical lymph nodes remains undefined.
The benefit of concurrent chemoradiation therapy of these patients is uncertain because their primary sites are small or absent , and neck control after resection followed by irradiation, or after irradiation alone, is excellent in patients with cancers of an unknown primary site.
Nasopharyngeal carcinoma is uncommon in most of the world. Endemic areas include southern China, northern Africa, and regions of the far Northern Hemisphere.
The incidence per 1, population ranges from Gender and age The incidence of nasopharyngeal cancer peaks in the fourth to fifth decades of life, and the male-female ratio is 2. Both patient age at disease onset and male-female ratio are lower for nasopharyngeal cancer than for other head and neck malignancies. They include diet, viral agents, and genetic susceptibility. Populations of endemic areas have a diet characterized by high consumption of salt-cured fish and meat.
Studies reveal an association between EBV and nasopharyngeal carcinoma. Anti-EBV antibodies have been found in the sera and saliva of patients with this type of carcinoma. Anatomy and pathology The nasopharynx communicates anteriorly with the nasal cavity and inferiorly with the oropharynx. The superior border is the base of the skull. The lateral and posterior pharyngeal walls are composed of muscular constrictors. Posteriorly, the nasopharynx overlies the first and second cervical vertebrae.
The eustachian tubes open into the lateral walls. The soft palate divides the nasopharynx from the oropharynx. Cancers arising in the nasopharynx are classified using WHO criteria: type 1 denotes differentiated. The TNM staging system for cancers of the pharynx is outlined in Table 5. Other presenting symptoms include a change in hearing, sensation of ear stuffiness, tinnitus, nasal obstruction, and pain.
Deficits are manifested by changes in ocular motion. Involvement of CN V may also occur; this is manifested by pain or paresthesia high in the neck or face. Level V metastases Unlike malignancies of the oral cavity and oropharynx, nasopharyngeal cancers often metastasize to level V lymph nodes. Bilateral metastases are common. Treatment of nasopharyngeal cancer usually involves radiation therapy for the primary tumor and draining lymph nodes. Surgical resection has high morbidity and is seldom entertained.
Nasopharyngeal cancer is distinguished from other sites of head and neck cancer by its radiosensitivity and chemosensitivity. The final report of the Intergroup trial confirmed that for patients with locally advanced nasopharyngeal cancer, concurrent cisplatin chemotherapy with radiation therapy followed by systemic chemotherapy provided a clear survival benefit when compared with treatment with irradiation alone.
As mentioned previously, surveillance after treatment of head and neck cancer is mandatory, as early detection of second primary cancers or locoregional recurrence affords the best chance for disease control. Nearly two-thirds of patients whose head and neck cancer recurs develop a tumor at or near the primary site or in the neck nodes. Eighty percent of head and neck cancer recurrences eventuate within 2 years.
Differentiating between recurrent carcinoma and significant sequelae of radiotherapy is a difficult clinical problem at all sites within the head and neck.
Any suspicious mucosal changes, enlarged nodes in the neck, or discrete subcutaneous nodules warrant prompt biopsy. Different choices of first treatment ie, surgery or radiation therapy and the intensity of follow-up influence success in treating recurrence. Aggressive surgical intervention should be offered to two groups of patients with recurrent local or regional disease: those whose therapy is chosen with curative intent and those who have the prospect for significant palliation.
The types of recurrence that may be approached surgically with the greatest likelihood of success include 1 metastases in the neck after initial treatment limited to the primary tumor alone and 2 reappearance or persistence of cancer at a site previously treated with radiotherapy alone.
Salvage resection may also be considered in other situations, however. They include the appearance of cancer in the neck after prior irradiation or neck dissection, at the margins after previous resection, and even at the base of the skull.
Surgery is the standard of care for the treatment of recurrent disease, but there is a growing body of evidence suggesting that reirradiation with concurrent chemotherapy can cure selected patients when resection is not possible. You might feel like food is stuck in your throat. You may cough or feel like food or liquid are going into the airway windpipe. Head and neck cancer can affect your voice. It might sound different. It may be quieter or husky.
It may sound as if you have a cold all the time. Or you might slur some of your words or have trouble pronouncing certain sounds.
Ear pain is common with throat cancer. You may experience ringing in the ears. Throat cancer can affect breathing.
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