Diagnosis and Procedures
Types of Head and Neck Cancer
Below are some descriptions to help you better understand your (or your loved one's) diagnosis. While not all the information is covered, it will give you a general description and greater knowledge. If you still have questions take the opportunity to ask your doctor for further explanations.
See our Glossary of Terms for other medical definitions.
Cancer of the Nasopharynx
- Laryngeal Cancer
- Other Cancers on the neck
The larynx is the area of the body from the hyoid bone to the epiglottis. It is critical to voice production, swallowing and breathing. Ninety-five percent of laryngeal cancers are SQUAMOUS CELL CARCIMONA. These tumors arise from the cells of the membranes lining the larynx. Less common tumors of the larynx include carcinosarcoma and verrucous carcinoma. In addition, some tumors that benign, or noncancerous also occur in the larynx. Although the cause of cancer is unknown, there is a strong association between smoking and alcohol use and laryngeal cancers. More than 95% of laryngeal cancers occur in smokers. Continuing to smoke during and after treatment significantly increases your risk of recurrence.
Cancers of the larynx are classified by their site of origin. The larynx is commonly divided into three segments: 1) Supraglottic 2) Glottic and 3) Subglottic.
TheSupraglottic Larynxis comprised of the epiglottis, the aryepiglottic folds, the ventricular folds and the laryngeal ventricles. Tumors in this area can cause hoarseness or airway obstruction and or swallowing problems. Tumors may be fairly large, before they are diagnosed. They are usually treated with surgery (partial laryngectomy or total) and radiation.
Glotticcancer refers to the vocal folds. Generally, hoarseness and airway obstruction are the first signs. If a tumor is confined to the larynx, it may be successfully treated with radiation and or laser cordectomy.
Subglottic tumors occur infrequently. They are in a less accessible area of the larynx and therefore often required a total laryngectomy. The surgeon may also have to remove all or part of the thyroid glands and adjacent lymph nodes.
In addition to these laryngeal tumors, cancers can directly involve the larynx from nearby sites. For example, a cancer on the tongue base may invade the epiglottic space.
Medical testing for cancer of the larynx may include chest x-ray, complete blood count, serum chemistry studies, pulmonary function studies, and MRI. Your doctor will perform a biopsy before proceeding with treatment of the tumor to confirm the diagnosis and often an endoscopy to determine the extent or stage of the tumor.
Treatment of laryngeal cancer traditionally includes surgery, radiation and chemotherapy. Treatment may consist of a single form, or be a combination of several modalities. The combination that is best suited for you is determined by multiple factors. Factors include: placement of tumor, size of tumor, patient's general health. Also of concern to is whether or not the cancer has invaded the LYMPH NODES or if it has METASTHESIZED. Your physician's primary concerns are eliminating the cancer and preserving function. Please ask your medical specialist for further information on the specific procedures relevant to your case.
Soft Palate Cancer
Cancer of the soft palate (or roof of mouth) is relatively rare. The soft palate anatomically divides the mouth from the nose. The overwhelming majority of tumors arise on the side facing the tongue. Although rare, these tumors are generally more readily visualized and thus are often identified earlier than other oral cancers. Larger tumors may create ulcerations or even perforation of the soft palate. Soft palate tumors tend to spread to the superior constrictor muscles and pterygoid fossa if left untreated.
Treatment of cancers in this region typically includes a combination of surgery and radiation. Radiation treatment is often the modality of choice for small lesions, as a full-thickness resection of the soft palate impairs speech production (Resonance- link to definition), and swallowing. In small lesions (less than one centimeter) surgery may be the primary form of treatment, because full closure of the tissue removed is possible. Large lesions that require both surgery and radiation typically also require the services of a Prosthodontist . This dental specialist, in conjunction with your speech and swallowing specialist will create a prosthesis to fill the area of removed tissue to restore function.
Supracricoid Partial Laryngectomies
The Supracricoid Partial Laryngectomies (SCPL) are a subset of surgical procedures that are available to the Head and Neck Surgeon for the management of selected cancers of the larynx. The SCPLs are a subset of conservation laryngeal operations.
SCPL refers to the resection of the diseased or affected part of the larynx that is removed at the time of operation. The defect in the larynx is then reconstructed at the time of operation with what is known as a crico-hyoidal impaction. The specific type of impaction is either a cricohyoidoepiglottopexy, a cricohyoidopexy, or a tracheocricohyoidoepiglottopexy. Exactly which reconstruction is used is determined by the location of the patient's cancer, the extent of involvement of the tumor and the patient's overall condition. The SCPLs are all alike in that the anterior component of the vocal cords is removed bilaterally in addition to the immediate area above and below the vocal cords. If the tumor then extends either above or below the actual vocal cords (or glottis), then either of the above reconstructions is performed. In addition, one of the arytenoids (the cartilage that controls the vocal cords) can also be removed.
The benefits of the SCPLs are that rather large tumors can be effectively removed from the larynx while still preserving swallowing, speech and the airway functions of the larynx. While the patient's voice will never be normal after any of the supracricoid partial laryngectomies, the patient is able to communicate readily without the aid of any prosthesis or electronic device, and most importantly, the vast majority of patients do not need a permanent tracheostomy. A tracheostomy is necessary in the immediate post-operative period, but we are usually able to remove this in the few days after surgery, before the patient even leaves the hospital. Then, as the surgery and tracheostomy sites heal, the patient relearns how to speak and swallow. Obviously then, if we can avoid the permanent hole in the neck needed with more traditional laryngeal surgeries, then the patient can lead a more normal and active life with fewer, if any, restrictions.
The SCPLs do, however, have some contraindications. Not everyone is a candidate for conservation laryngeal surgeries, and very specific criteria have to be met to be able to perform the resection and reconstruction while still removing the entire tumor. Obviously, the first goal of any cancer operation is to remove all of the cancer. In addition, pulmonary function must be assessed before performing any of the above surgeries. While patients recuperate from their surgery, there is often a moderate amount of aspiration of saliva and even diet into the airway. While the patient relearns to swallow in usually no more than seven to ten days, it is important that he have healthy lungs so that he can tolerate this small degree of aspiration. In addition, SCPLs do not give patients a normal voice. Patients are, however, able to communicate readily and without the use of any assisted devices.
Once a patient is found to have cancer of the larynx, it is then up to his treating surgeon to assess the extent of the disease and consider the patient's surgical options. If SCPL is an option, then we like to use it as we feel that not only is the patient's long-term function significantly improved as compared to traditional therapy but also long-term cancer control is not sacrificed.
Floor of Mouth Cancer/Buccal Cancer
The buccal cavity includes the inner surface of the lips. The Floor of mouth is the "U"-shaped lining over the hyoglossus and mylohyoid muscles. It is a deep area, extending all the way to the mandible (lower jaw). The buccal cavity (BC) and floor of mouth (FOM) are intimately connected. The move in synchrony with the tongue during to allow one to swallow. The major salivary glands empty secretions through the membranes that line the FOM and BC.
Over 97% of all cancers of this region are SQUAMOUS CELL CARCINOMA. Leukoplakia and erythroplasia often appear prior to a cancer diagnosis. Because of their interconnection with tongue and mandible, tumors in this region tend to spread locally. Distal metastasis is rare. The major risk factors in developing cancers in this region are alcohol and tobacco use. Other possible causes include, the Herpes Simplex 1 virus, and marginal oral hygiene. Chronic irritants, such as dentures are not strongly correlated with FOM/BC cancer.
The treatment for cancers of the FOM and BC is determined primarily from the stage of the lesion. The physician's primary goals in treatment are elimination of cancer and preservation of function/appearance. The two primary treatments are radiation, surgery, or a combination of both. Neck surgery may also be required if the cancer has spread to the lymph nodes. Techniques developed over the past decade have greatly improved quality of life for patients with FOM and BC cancer.
The tonsils are made of lymphoid tissue, which contains cells of the immune system that are involved in fighting infection. The palatine tonsils are what we commonly refer to as "the tonsil;" however, there is also a patch of lymphoid tissue at the base of tongue, called the lingual tonsil. Other lymphoid tissue occurs in the nasopharynx (high in the pharynx behind the nasal passages) and this is referred to as the adenoid. Together, the palatine tonsils, the lingual tonsil and the adenoid make up a ring of lymphoid tissue in the pharynx - Waldeyer's ring.
The most common cancers that occur in the tonsils are squamous cell carcinoma (SCCA). Lymphoma can also occur in the tonsil. The cancers that occur in the tonsil are similar to those that occur elsewhere in Waldeyer's ring. Lymphoepithelioma is an older term for a non-keratinizing undifferentiated SCCA.
The risk factors for SCCA are smoking, drinking and in particular the combination of heavy smoking with heavy drinking. More recently viral infection has been implicated in the etiology of SCCA in the upper aerodigestive tract. Human papilloma virus (HPV) DNA has been found in SCCA of the tonsil. However, we do not know what role HPV plays in the development of cancer at this location. Risk factors notwithstanding, there are individuals who develop SCCA in the tonsil (and at other sites in the upper aerodigestive tract) without having any of the known risk factors. Currently, we have limited understanding of what factors may lead to development of SCCA of the tonsil in individuals who neither smoke nor drink. It may be that DNA viruses such as HPV may play a role in the process of carcinogenesis in these individuals.
Signs and Symptoms
Most tonsilar cancers are relatively quiet until they become very large or ulcerate. Most often, the first presenting symptom is that of a neck mass. Many tonsilar cancers have early spread to lymph nodes in the neck (cervical metastasis) and this is a common presenting feature of these cancers. The cervical metastases tend to be cystic and can be confused with a benign neck lump called a branchial cleft cyst. Because of the lack of symptoms in tonsilar SCCA, tonsilar asymmetry (one tonsil being larger than the other) in an adult is sufficient reason to perform a tonsillectomy to rule out cancer. In addition, if SCCA is diagnosed in the neck and the site of origin is not identified, a tonsillectomy is usually performed to rule out the tonsil as the source of the cancer. Fortunately, tonsilar SCCA does not have a high rate of early spread to distant sites such as the lung.
Tonsilar SCCA is staged according to size of the tumor and degree of involvement of bone and deep muscles. It is also important to evaluate the neck for metastatic spread of SCCA, which tends to occur rather early in the course of the disease. Distant spread is relatively infrequent and, in most cases, can be ruled out with a simple chest X-ray. In cases where there is extensive or bilateral neck disease a CT scan of the chest or a whole body PET scan may be obtained.
Options for treatment depend on size of the tumor, whether adjacent structures (tongue, palate, bone) are involved, and degree of neck spread. Surgery followed by radiation therapy is the form of treatment that offers the best chance of cure. Surgery can sometimes be done through the mouth (transorally) as one would do a tonsillectomy in a child; however, this approach can only be done for the smaller tumors. Larger tumors usually require a different approach by splitting the mandible (mandibulotomy and mandible swing) or by entering the pharynx laterally (lateral pharyngotomy). A neck dissection with removal of lymph nodes structures is almost always performed because of the high rate of early tumor spread to the neck. Patients who have mandibulotomy or pharyngotomy as the approach for tumor removal require a temporary tracheostomy tube which in general stays in place for 4-14 days.
Combination chemotherapy and radiation therapy (chemoradiation) has also been used for these tumors. In these cases, neck dissection is performed afterward for any patient that initially presented with palpable neck disease. Combination chemoradiation is still in its early stages and we do not have complete information on tumor control with this modality, although the early results suggest cure rates that are comparable to those obtained with surgery. For smaller tumors, the results with surgery, both in terms of tumor control and functional outcome, are better with surgery followed by postoperative radiotherapy. The decision to choose one form of treatment over another has to be individualized. Factors that influence the choice of treatment are the size and location of the tumor, the experience of the treating team (surgeon, radiation oncologist, and medical oncologist), and the preference of the patient and his/her family.
Tumors of the tonsil, like most tumors of the upper aerodigestive tract, can affect speech and swallowing functions. The treatment of these tumors, whether it is surgery or radiation or chemotherapy, can also interfere with normal speech and swallowing. The process of rehabilitation involves prevention of complications and early intervention to maximize functional outcome. Dental care is quite important as is nutrition, swallowing ability and adequate social support.
Click here for details about surgical procedures.
A system of classifying and comparing tumors was developed. This information is included in this site for educational purposes and is not meant to suggest severity prognosis. Please contact your healthcare provider for specifics concerning your tumor.)
Medical Disclaimer: Patients and consumers reading the articles herein should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians.
© 2010 The Milton J. Dance Jr. Head and Neck Center. All rights reserved.