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What is Head and Neck Cancer ?

Head and neck oncology deals with cancers that arise in the oral cavity, pharynx, larynx, nasal cavity, paranasal sinuses, salivary glands, and sometimes the thyroid gland. These cancers are often associated with risk factors like tobacco use, alcohol consumption, HPV infection, and betel nut chewing (common in South Asia). Here’s a structured overview of the subject

Epidemiology
  • Common in India and other developing countries.
  • Tobacco and alcohol are the leading causes.
  • HPV-related oropharyngeal cancers are increasing globally, with distinct biological behavior and better prognosis.
Clinical Presentation

  • Symptoms depend on the site:

  • Oral cavity: Non-healing ulcers, bleeding, difficulty in chewing or speaking.

  • Oropharynx: Dysphagia, odynophagia, referred otalgia.

  • Larynx:Dysphagia, odynophagia, referred otalgia.

  • Nasopharynx: Nasal obstruction, epistaxis, cranial nerve palsies.

  • Salivary glands: Painless swelling, sometimes facial nerve involvement.

  • Advanced cases may present with neck lumps (lymphadenopathy) or systemic symptoms.

Diagnosis

  • Clinical evaluation: Comprehensive head and neck examination with indirect or direct laryngoscopy.

  • Imaging: Contrast-enhanced CT or MRI for local extent; PET-CT for distant metastases.

  • Biopsy:Confirmatory histopathological diagnosis.

  • HPV and EBV testing: Important for oropharyngeal and nasopharyngeal cancers, respectively.

Treatment Modalities

Surgery: Assist in confirming cancer diagnosis and determining its stage using imaging, biopsy reports, and molecular studies.

Radiotherapy:

  • External Beam Radiotherapy (EBRT): IMRT is the gold standard for precise dose delivery, sparing critical structures.

  • Brachytherapy: Excellent for early oral cavity, lip, or tongue cancers, where user expertise can play a significant role.

Chemotherapy:

  • Concurrent chemoradiotherapy for locally advanced cases (cisplatin-based regimens).

  • Induction chemotherapy in selected advanced cases.

Immunotherapy and Targeted Therapy:

  • EGFR inhibitors like cetuximab.

  • Immune checkpoint inhibitors (e.g., pembrolizumab) for recurrent/metastatic disease.

Radiotherapy in Head and Neck

Role of Brachytherapy:

  • Early-stage tongue, lip, and buccal mucosa cancers.

  • Brachytherapy: Boost after EBRT for close/positive margins or residual disease.

Challenges in EBRT:

  • Ensuring sparing of organs-at-risk like the spinal cord, optic apparatus, and salivary glands.

  • Managing acute toxicities like mucositis, dermatitis, and xerostomia.

  • Adaptive radiotherapy: Useful for volumetric changes during treatment.

Follow-Up and Survivorship

  • Regular surveillance to detect recurrence or second primaries.

Management of long-term sequelae:

  • Xerostomia, dysphagia, trismus.

  • Osteoradionecrosis of the jaw.

  • Psychological support and rehabilitation.

The treatment of head and neck cancers is multidisciplinary, involving surgery, radiotherapy, chemotherapy, immunotherapy, and supportive care. The choice of modality depends on the site, stage, histology, patient’s performance status, and goals of treatment (curative or palliative). Below is a detailed overview:

Surgery

Primary role: For accessible tumors and resectable disease.

Procedures:

  • Wide local excision with clear margins.

  • Neck dissection (selective, modified, or radical) for nodal metastases.

  • Reconstructive surgery using flaps (e.g., free flap, pedicled flap) for functional and cosmetic rehabilitation.

Indications:

  • Early-stage tumors (T1-T2).

  • Advanced tumors (T3-T4) in combination with adjuvant therapy.

  • Salvage surgery for recurrent disease.

Radiation Therapy (RT)

Techniques:

  • External beam radiotherapy (EBRT): IMRT, VMAT, IGRT for precise dose delivery while sparing normal tissues.

  • Brachytherapy: Ideal for small, localized tumors, especially in the oral cavity or lip.

Indications:

  • Definitive RT for early-stage cancers (especially laryngeal, nasopharyngeal).

  • Adjuvant RT after surgery for high-risk features (positive margins, extracapsular spread).

  • Palliative RT for symptom control (e.g., pain, bleeding).

Dose:

  • Definitive: 66-70 Gy in 33-35 fractions.

  • Post-operative: 60-66 Gy in 30-33 fractions.

Chemotherapy

Role:

  • Concurrent chemoradiation (CRT) for locally advanced disease.

  • Induction chemotherapy in selected cases.

  • Palliative chemotherapy for metastatic disease.

Agents:

  • Platinum-based: Cisplatin (standard in CRT).

  • Taxanes (e.g., paclitaxel), 5-FU.

  • Combination regimens (e.g., TPF: docetaxel, cisplatin, 5-FU).

Immunotherapy

Checkpoint inhibitors: Used in recurrent/metastatic settings.

Pembrolizumab and nivolumab (anti-PD-1 antibodies) have shown survival benefits.

Particularly effective in HPV-positive tumors.

Targeted Therapy

Cetuximab (anti-EGFR antibody)

  • Used in combination with RT for patients intolerant to cisplatin.

  • Also used in the metastatic setting.

Multimodal Approaches

Early-stage (I-II): Single modality treatment (surgery or RT).

Locally advanced (III-IV): Multimodal treatment (CRT or surgery + adjuvant therapy).

Recurrent/metastatic: Palliative systemic therapy or immunotherapy.

Palliative Care

Symptom management (e.g., pain relief, airway obstruction, dysphagia).

Nutritional support: : Feeding tubes or total parenteral nutrition (TPN) for dysphagic patients.

Psychosocial support: Addressing body image issues, speech therapy, and emotional well-being.

Role of Brachytherapy in Head and Neck Cancer

Sites:

  • Lip, oral cavity, oropharynx.

Advantages:

  • Delivers high doses locally while sparing surrounding tissues.

Techniques:

  • Interstitial implants using needles/catheters.

    High-Dose-Rate (HDR) or Low-Dose-Rate (LDR) brachytherapy.

Emerging Modalities

Proton beam therapy: For challenging cases near critical structures (e.g., skull base).

Hypofractionation: Shortened radiation schedules for select patients.

Liquid biopsy: Monitoring disease with circulating tumor DNA (ctDNA).

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