Head & Neck Cancer 2

Overview of Cancers in Oral Cavity and Oropharynx - Focus on specific cancers of the oral cavity and oropharynx, including visual case examples.

Definition of Oral Cavity and Oropharynx
  • Oral Cavity: Extends from the vermilion border of the lips to the anterior pharyngeal arches, the circumvillipapillae of the tongue, and the posterior rim of the hard palate.
  • Oropharynx: More posterior than the oral cavity, including the base of the tongue at the anterior border, the pharyngeal wall at the posterior border, the tonsillar fossae laterally, and the soft palate above.
Cancer Sites in Oral Cavity and Oropharynx
  • Distinction between oral cavity and oropharynx cancers is crucial; while lumped together in discussions, they are separate subsites.
  • Common sites of cancer include:
    • Tongue
    • Mandible
    • Floor of the mouth
    • Alveolar ridge
    • Tonsils
    • Palate
  • Affected Areas: Tonsillar fossa and palate are the most commonly affected, followed by the base of the tongue.
  • Indicates the importance of tonsillar tissue, which plays a role in immune response and may contribute to cancer development when failures occur.
Importance of Oral Exams in Diagnosis
  • Oral cancers are visible, and conducting thorough visual examinations is vital.
  • Speech-language pathologists (SLPs) are encouraged to perform oral motor exams on every patient, as they might be the first clinicians to identify cancers in these areas.
    • Routine exams by doctors and nurses may overlook oral examinations.
Visual Exam and Identifying Tumors
  • Clinical examples:
    • Cancerous Mass on Tongue: Visualization will reveal sulci or irregular regions, indicating cancer.
    • Ulcerated Tissue Under Tongue: Sign of floor of mouth cancer.
    • Swollen Tonsil with Mass: Indicative of tonsillar cancer.
  • Comfortability: Understand that patient discomfort may arise during examinations; however, thorough visual checks are crucial.
General Risk Factors for Head and Neck Cancers
  • Tobacco Use: Smoking cigarettes, cigars, pipes, and using smokeless tobacco (chewing tobacco, snuff) are major risk factors across all head and neck cancer sites.
  • Alcohol Consumption: Heavy and prolonged alcohol use, especially when combined with tobacco, significantly increases risk.
  • Human Papillomavirus (HPV) Infection: Primarily associated with oropharyngeal cancers, particularly those affecting the tonsils and base of the tongue. HPV-positive oropharyngeal cancers often have different prognoses and treatment responses than HPV-negative cancers.
  • Poor Oral Hygiene: Can contribute to chronic irritation and infection, increasing risk, especially in the oral cavity.
  • Ultraviolet (UV) Light Exposure: A primary risk factor for lip cancer.
  • Age: The risk of most head and neck cancers increases with age, typically affecting people over 50.
Advanced Diagnostic and Staging Methods
  • Beyond visual exams and initial endoscopic procedures, further diagnostic steps are crucial for definitive diagnosis and staging:
    • Biopsy: A definitive diagnosis requires a tissue biopsy, where a small sample of suspicious tissue is removed and examined under a microscope by a pathologist. This determines the presence of cancer cells and their type.
    • Imaging Studies:
    • Computed Tomography (CT) Scan: Used to determine the extent of the primary tumor, involvement of surrounding structures, and lymph node spread.
    • Magnetic Resonance Imaging (MRI): Provides detailed images of soft tissues, particularly useful for assessing tumor depth and neural involvement.
    • Positron Emission Tomography (PET) Scan: Helps detect cancer spread to distant sites (metastasis) and can identify primary tumors not visible on other scans. Often combined with CT (PET-CT).
    • Endoscopy with Biopsy: For laryngeal and hypopharyngeal cancers, a direct laryngoscopy or pharyngoscopy under anesthesia allows for detailed examination and biopsy.
  • Staging System: The TNM (Tumor, Node, Metastasis) system is used to describe the extent of cancer:
    • T (Tumor): Describes the size and extent of the primary tumor.
    • N (Nodes): Indicates whether the cancer has spread to nearby lymph nodes.
    • M (Metastasis): Denotes whether the cancer has spread to distant parts of the body.

Laryngeal Cancer

  • Types: Involves supraglottic, subglottic, and glottic larynx.
  • Prognosis: Generally better than other head and neck cancers due to clear symptoms related to the vocal folds.
  • Common Symptoms:
    • Change in voice quality (roughness or hoarseness).
  • Dysphonia: Persistent hoarseness is an indicator for imaging and evaluation.
  • Laryngeal Imaging Guidelines:
    • According to the American Academy of Otolaryngology, laryngeal visualization (laryngoscopy) is necessary for patients with persistent dysphonia lasting four weeks or more.
    • Misdiagnosis often occurs with unnecessary treatments like antibiotics or anti-reflux medications.
Laryngeal Anatomy Overview
  • Endoscopic view of glottic larynx includes:
    • Ventricular Folds: Lateral bulges next to true vocal folds.
    • Laryngeal Ventricle: Dark shadow adjacent to true vocal folds.
    • True Vocal Folds: Pearly white structures with a smooth edge visible under endoscopy.
    • Anatomical Areas: Subglottic space, cricoid cartilage, and tracheal rings.
Glottic Carcinoma Overview
  • T Classification System: (Tumor type and extent)
    • T1A: Cancer confined to one true vocal fold.
    • Visualization identifies abnormal, bulky tissue, possibly an exophytic lesion.
    • T1B: Bilateral involvement of vocal folds, with irregular appearances.
    • T2: Spread beyond true vocal folds into supraglottic areas.
    • T3: Immobility in one vocal fold or paralysis indicating progressive cancer.
  • Supraglottic Carcinoma: Can lead to resonance issues and is harder to diagnose due to lack of symptoms until later stages.
  • Hot Potato Speech: Patients with large supraglottic masses often speech impairments characterized by altered resonance.
Advanced Voice and Resonance Impact
  • Useful Cases: Both voice quality analysis and resonance disorders during clinical assessments demonstrate early signs of serious throat issues.
  • Clinical Guidelines: Emphasize importance of thorough voice assessments and proper referrals.

Hypopharyngeal Cancer

  • Defined as cancers arising in the hypopharynx or laryngopharynx, typically from the piriform sinus.
  • Common sites include the posterior pharyngeal wall and post-cricoid area; however, symptoms often appear late when tumors grow large enough to impact swallowing or cause discomfort.
  • Prognosis and Treatments: Poor prognosis, with chemotherapy and radiation as common treatments. Surgery, such as laryngopharyngo-esophagectomy, may be necessary if non-curative.
Role of Speech Pathology
  • SLPs can identify early signs of cancer, significantly impacting treatment outcomes.
  • Example:
    • Early-stage cancer identified during a swallow study leading to prompt imaging and treatment.
  • Modified Barium Swallow Study: Essential for assessing swallowing function and identifying obstructions, leading to timely referrals for biopsies and imaging.
General Treatment Approaches for Head and Neck Cancers
  • Treatment plans are highly individualized based on the cancer type, location, stage (TNM), and patient's overall health.
  • Surgery: Often the primary treatment, involving the removal of the tumor and sometimes surrounding healthy tissue or lymph nodes.
  • Radiation Therapy: Uses high-energy rays to kill cancer cells or shrink tumors. Can be used alone or in combination with surgery or chemotherapy.
  • Chemotherapy: Uses drugs to kill cancer cells, often administered intravenously. It can be used to shrink large tumors before surgery or radiation, or to treat cancer that has spread.
  • Targeted Therapy: Drugs that target specific genes or proteins involved in cancer growth and survival, often with fewer side effects than traditional chemotherapy.
  • Immunotherapy: Uses the body's own immune system to fight cancer. These treatments typically unblock immune cells so they can recognize and attack cancer cells more effectively.

Summary of Key Points

  • Identification of head and neck cancers often comes down to the thorough evaluations done by SLPs.
  • Knowledge of anatomy, cancer symptoms, and appropriate clinical practices can save lives and improve patient outcomes.