Head and neck tumours affect most of the small organs contained in the head and neck, which are extremely important in terms of function, excluding the brain, eyes and thyroid. These types of tumours affect a visible part of the body, and can therefore compromise the individual’s body image and, consequently, their quality of life.

Symptoms

The symptoms of a head and neck tumour can vary widely depending on the location of the tumour, and are usually identified by a general practitioner or dentist, who will advise the patient to schedule a specialised visit with an otolaryngologist or a maxillofacial surgeon.

Be sure to bring any mouth injuries, even if painless or small, including any nodules, canker sores, ulcers, plaques, and miscellaneous growths, to your physician’s attention.

The anatomical locations from which head and neck tumours can originate are the following:
–          Lips
–          Tongue
–          Throat
–          Mouth
–          Nasal passages
–          Larynx and vocal organs
–          Salivary glands
–          Nasopharynx
–          Facial skin
–          Paranasal sinuses

The initial symptoms encountered are the following:
–          Signs of a mass
–          Presence of a lump in the neck
–          Difficulty/pain swallowing
–          Tongue pain
–          Throat pain
–          Persistent hoarseness
–          Dysphonia
–          Dysphagia
–          Nosebleeds
–          Nasal blockage on one side
–          Difficulty inhaling air
–          Dyspnoea
–          Nasal obstruction
–          Mouth ulcers that don’t heal
–          White or red spots in the mouth
–          Swelling in the neck.

The subsequent symptoms depend on the location of the tumour, and may include the following:
–          Pain
–          Nerve paralysis
–          Trismus
–          Halitosis
–          Paraesthesia

Specialists

The clinical figures to whom patients can turn are the following:

  • General practitioner and dentist: these are the first figures to turn to if any suspicious symptoms are encountered.
  • Otolaryngologist or maxillofacial surgeon: Proceeds with the physical examination (direct observation) and palpation of the suspicious lesions. Checks all the mucosal surfaces, may request in-depth diagnostic tests, perform an endoscopic examination, and perform a biopsy. These are the specialists who operate on patients who are candidates for surgery.

Rhinofibrolaryngoscopy is an examination in which an optical instrument is inserted through a nostril to inspect the nasal passages (nasopharynx and pharyngolarynx), thus allowing the specialist have a complete overview any otolaryngological diseases present.

  • Pathologist: the specialist who performs the biopsy and analyses the collected tissue in the laboratory. The pathologist will diagnose the tumour, and may determine that the tissue samples require further in-depth analysis.
  • Oncologist: an oncologist is contacted when the tests confirm the presence of a tumour, especially if the tumour is locally advanced and/or metastatic. Working with other specialists, the oncologist manages the patient’s drug treatment, prescribes the postoperative staging assessments, and determines the most suitable medical therapy.

Staging is a way of schematically describing how large a tumour is, and how far it has spread from its original site of development.

  • Radiotherapists: the specialists who carry out radiotherapy.
  • Multidisciplinary team: the team of experts consisting of the otolaryngologist or maxillofacial surgeon, the oncologist, the anatomopathologist, and the radiotherapist. Together they manage the intervention and determine the therapy to be provided. They can also often be supported by a dietician, a speech therapist, and a psychologist, in order to tackle the treatment plan with a more integrated and holistic approach.

Exams

Head and neck tumours are diagnosed using the following exams:

  • Physical examination

Includes inspection of the oral cavity, nose and neck by the specialist; palpation of the lips, gums, cheeks and neck is also performed to check for any nodules.

  • Endoscopy

A procedure that allows for the examination of areas of the body not visible to the naked eye or through palpation. It involves the use of a thin tube-like instrument with a light source at one end. In most cases, endoscopies can be performed at the clinic, with no need for anaesthesia.

  • Histological examination

This consists of a laboratory analysis of the tumour tissue, during which the material taken with the biopsy is analysed and studied under a microscope. The biopsy can be done endoscopically or, where possible, by taking a sample of the tissue from the mouth.

  • Tumour biomarkers

Biomarkers are biological molecules that can be detected in blood (whole blood, or else plasma or serum), urine, faeces, and other body fluids or tissues, with an approach that can be either non-invasive or tissue-derived (imaging or biopsy). They can help oncologists determine the prognosis (prognostic biomarkers) or predict the patient’s response to a specific therapy (predictive biomarkers).

There’s a wide variety of biomarkers, including proteins (enzymes or receptors), nucleic acids (microRNAs or other non-coding RNA chains), antibodies, and peptides. A biomarker can also be metabolomic. Genetic markers can be hereditary, and can therefore be detected as modifications of the germline DNA sequence and isolated from blood, saliva, or mouth cells, or else they can be somatic, and can therefore be identified through DNA mutations in the tumour tissue.

In recent years, the number of predictive biomarkers has steadily increased thanks to the advent of increasingly targeted therapies, thus allowing the most suitable patients to gain access the best treatments. This innovative concept is referred to as personalised medicine.
Modern biomarker determination techniques are now widely used in common clinical practice, and have further promoted the concept of personalised medicine.

In fact, several immunotherapy drugs were immediately linked to specific biomarkers. This is the case with PD-L1, which is now increasingly recognised as a predictor of response to the class of anti-PD-1 immunotherapy drugs for lung tumours, head and neck tumours, and urothelial cancer.

The PD-L1 assessment is done by performing an immunohistochemistry test on the biopsied tissue: a technique widely used in the diagnosis of various diseases.

  • HPV test

The evaluation of human papillomavirus (HPV) positivity stage has prognostic value. The expression of the p16 protein, determined using immunohistochemical method on the biopsied tissue, is a surrogate marker of HPV infection, and its evaluation must be determined in oropharyngeal carcinomas.

  • Radiological examinations

Examinations like magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) are carried out in order to determine the size and shape of the tumour and/or its response to the treatment performed.

  • Magnetic resonance

Usually used for all head and neck tumours, except those affecting the laryngeal and hypopharyngeal sub-sites; provides for a more detailed view of the soft tissues. With the use of contrast media, MRI is able to provide more information on the intrinsic characteristics of the tumour, the extent of the disease, and any muscle infiltration.

  • Computed tomography

Allows the tissues, bone structures, lymph nodes and blood vessels to be checked. Used in the case of contraindications to the use of MRI; also allows for any macroscopic bone involvement to be detected.

  • PET

Useful in detecting distant metastases and in post-treatment follow-up. The PET examination is increasingly being combined with CT without contrast medium (PET-CT), above all for the evaluation of metastatic disease and the identification of neoplasms with unknown primary sites.

Diagnosis

Head and neck tumours are diagnosed differently, depending on the type of cancer.

  • Oral cavity tumours

These types of tumours generally aren’t very complicated to diagnose: a simple biopsy under local anaesthesia is sufficient. In just a few minutes time, and with little very discomfort, it is possible to perform a histological diagnosis. Vocal cord tumours can be diagnosed early by performing a rhinofibrolaryngoscopy. After ultrasound, magnetic resonance and PET (imaging methods) will allow for proper staging to be carried out. There’s no type of blood test that’s capable of detecting the presence of an oral cavity tumour.

In order to be certain of whether a tumour is present, one must wait for the biopsy results. Cervical masses are usually biopsied by fine needle aspiration. Oral lesions, on the other hand, are usually analysed by incisional biopsy or exfoliative cytology. In the case of possible nasopharyngeal, oropharyngeal, and laryngeal tumours, an endoscopic biopsy is performed.

  • Laryngeal tumours

Laryngeal tumours are diagnosed by performing a rhinofibrolaryngoscopy of the nasal passages and an outpatient biopsy. An ultrasound of the neck with possible fine needle aspiration, an MRI with contrast medium, and a PET scan can also be subsequently performed.

In order to be certain of whether a tumour is present, one must wait for the biopsy results. Cervical masses are usually biopsied by fine needle aspiration. Oral lesions, on the other hand, are usually analysed by incisional biopsy or exfoliative cytology. In the case of possible nasopharyngeal, oropharyngeal, and laryngeal tumours, an endoscopic biopsy is performed.

  • Hypopharyngeal tumours

These types of tumours are diagnosed by performing an endoscopy and a biopsy. A CT scan, which is considered the best method for examining the hypopharynx, can also be subsequently performed.

In order to be certain of whether a tumour is present, one must wait for the biopsy results. Cervical masses are usually biopsied by fine needle aspiration. Oral lesions, on the other hand, are usually analysed by incisional biopsy or exfoliative cytology. In the case of possible nasopharyngeal, oropharyngeal, and laryngeal tumours, an endoscopic biopsy is performed.

  • Salivary gland tumours

Salivary gland (parotid, submandibular, or sublingual) tumours can be diagnosed with a specialist visit, with a targeted ultrasound examination being performed to allow for the fine needle aspiration of cell samples from the suspicious areas. Further investigations with magnetic resonance can later be performed.

In order to be certain of whether a tumour is present, one must wait for the biopsy results. Cervical masses are usually biopsied by fine needle aspiration. Oral lesions, on the other hand, are usually analysed by incisional biopsy or exfoliative cytology. In the case of possible nasopharyngeal, oropharyngeal, and laryngeal tumours, an endoscopic biopsy is performed.

Prognosis

Prognosis for head and neck tumours can vary considerably, and can depend on the following:

  • The size of the primary tumour
  • The primary site of the tumour
  • The aetiology of the tumour
  • The presence of regional or distant metastases, and lack of radicality in the case of surgical therapy

The prognosis is usually good when the diagnosis is made early and is followed up with prompt and adequate treatment. Neck and head tumours manifest themselves locally with metastases to the cervical regional lymph nodes; distant metastases, which can affect the lungs and other organs, only occur later, in patients who are in an advanced stage of the disease. Advanced metastases greatly reduce the chances of survival.

The possibility of recovery is also reduced if the tumour invades adjacent muscle, bone or cartilage structures. The chances of recovery are also reduced in the case of perineural invasions, paralysis, and numbness with signs of advanced stage cancer.

Treatment

Factors that determine the treatment

Head and neck tumours are treated using a combination of therapies that act on a local level, such as radiotherapy or surgery, with systemic therapies, such as chemotherapy, molecular target therapy, and immunotherapy.
The treatment plan is determined based on several factors, such as:

  • The localisation of the tumour
  • The stage of the tumour
  • The success rate of the treatment
  • The side effects, and in particular the possibility of impairing the ability to speak, breathe or eat
  • The patient’s overall health status
  • The patient’s age

Treatment plans

Treatment plans for stage I and II tumours

When the tumour is stage I or II, it can be treated locally with radiation therapy or conservative surgery. The choice of treatment depends on the accessibility of the anatomical site.

Treatment plans for stage III and IV tumours

Advanced stage tumours often require multimodal treatment, which may include a combination of surgery, radiotherapy and chemotherapy.

Generally speaking, a tumour is considered operable when it is certain that no residual tumour cells remain, or the functionality of the affected organs is not compromised. The treatment of the disease requires the synergistic participation of various specialists, in order to come up with what is called a multidisciplinary opinion (or tumour board), and to plan the relative treatments.

In conjunction with the treatment, the patient must also:

  • Stop engaging in activities that are considered risk factors, such as tobacco use and alcohol consumption. In particular, patients who are smokers have a higher level of acute toxicity, increased comorbidities, a reduced likelihood of recovery;
  • Maintain healthy eating habits;
  • Visit the dentist, as radiotherapy treatment can lead to oral complications.

The first therapeutic approach is fundamental. The specialists involved in the treatment planning will determine the treatment plan based on the stage and characteristics of the tumour. While recovery is the main goal, quality of life and the functions of the organs affected, including the ability to speak, swallow, taste and breathe, are also considered extremely important.

Follow ups

Once the treatment has been completed, the specialists will advise the patient to undergo a series of periodic checks (follow ups) in order to treat any side effects of the treatments, to catch any relapses early on, and to help the patient to resume a normal lifestyle.

During this phase, diagnostic imaging and physical examinations are particularly important, as they allow for any relapses and newly formed tumours to be caught early on.

Treatment of relapses

Treatment of recurring tumours is complex. The multidisciplinary team will evaluate the best therapeutic surgical and/or pharmacological approach.

Bibliography

Diagnosis

Treatments