Head and Neck Cancer

H&N Cancer Overview - Basics & Bad Habits

• Predominantly Squamous Cell Carcinomas (SCC) >90% from upper aerodigestive tract (UADT) mucosa.
• India: High incidence, often linked to regional habits like tobacco and betel quid chewing.
• Key Risk Factors ("Bad Habits"):
  • Tobacco (smoking/smokeless): Primary etiological agent, dose-response relationship. 📌 Tobacco: Chief Culprit.
  • Alcohol: Synergistic effect with tobacco, significantly ↑ risk.
  • Betel Quid (Areca nut): Strong association with oral cancer; causes Oral Submucous Fibrosis (OSMF) - a precancerous condition.
  • Human Papillomavirus (HPV): Mainly HPV-16, linked to oropharyngeal cancers (tonsil, base of tongue); generally better prognosis.
  • Others: Poor oral hygiene, chronic irritation, radiation exposure, nutritional deficiencies (e.g., Plummer-Vinson syndrome).

⭐ Over 75% of head and neck cancers are linked to tobacco use (smoked or smokeless).

Staging & Spread - Mapping the Mayhem

• TNM System (AJCC 8th Ed. principles):

  • T (Tumor): Size & local invasion (T1-T4).
  • N (Nodes): Regional lymph node status (N0-N3).
    • N0: No nodes.
    • N1: Single ipsilateral, ≤ 3cm.
    • N2: Ipsilateral > 3cm-6cm / Multiple ipsi / Bilateral/Contralateral (all ≤ 6cm).
    • N3: Node > 6cm / Any node with Extranodal Extension (ENE).
  • M (Metastasis): M0 (no distant), M1 (distant).

• Key Neck Nodal Levels:

  • I: Submental/Submandibular
  • II: Upper Jugular
  • III: Middle Jugular
  • IV: Lower Jugular
  • V: Posterior Triangle
  • VI: Anterior Compartment

• Spread Patterns:

  • Lymphatic: Common, predictable.
  • Hematogenous: Lungs, liver, bone.

⭐ Extracapsular spread (ECS) or Extranodal Extension (ENE) in lymph nodes (pN+) significantly worsens prognosis and often indicates need for adjuvant chemoradiotherapy.

Clinical Clues & Diagnosis - Signs & Sleuthing

• Key Symptoms (Red Flags):
  • Oral: Non-healing ulcer/patch (>3 wks), pain, bleeding, trismus, loose teeth.
  • Laryngeal: Persistent hoarseness (>3 wks), stridor, dysphagia, hemoptysis.
  • Pharyngeal: Sore throat, dysphagia, odynophagia, referred otalgia (Trotter's - NPC), globus.
  • Nasal/Sinus: Unilateral obstruction, epistaxis, facial swelling/pain, proptosis.
  • Neck: Persistent lump (often painless, firm, fixed, >2cm).
  • General: Unexplained weight loss, fatigue.
• Diagnostic Approach:

> ⭐ Histopathological confirmation via biopsy is mandatory. FNAC is the primary step for suspicious neck nodes.
*   **Imaging:** CT (bone, nodes), MRI (soft tissue, perineural spread), PET-CT (mets, unknown primary).
![Lymph Node Groups of the Neck](https://ylbwdadhbcjolwylidja.supabase.co/storage/v1/object/public/notes/L1/Surgery_Head_and_Neck_Surgery_Head_and_Neck_Cancer/d21081df-f635-4b8e-923d-51b59f75a48d.jpg)

Management Modalities - Treatment Takedown

• Goal: Maximize cure, preserve organ function & Quality of Life (QoL). Multidisciplinary Team (MDT) essential.
• Core Modalities:
  • Surgery: Primary for most resectable tumors (oral cavity, larynx, salivary). Includes neck dissection (therapeutic/prophylactic). Reconstruction often needed (e.g., PMMC, free flaps).
  • Radiotherapy (RT): Definitive (e.g., early larynx, NPC), adjuvant (post-op), or palliative. Techniques: EBRT (IMRT, VMAT), Brachytherapy. Key toxicities: mucositis, xerostomia.
  • Chemotherapy (CT): Used as induction, concurrent with RT (CRT - a standard), adjuvant, or palliative. Agents: Cisplatin, 5-FU, Taxanes. Targeted therapy: Cetuximab (EGFR inhibitor).
  • Immunotherapy: PD-1 inhibitors (Nivolumab, Pembrolizumab) for recurrent/metastatic settings.
• Treatment Choice: Depends on primary site, TNM stage, histology, patient's performance status, and comorbidities.

⭐ Concurrent chemoradiation (CRT) with high-dose Cisplatin (100 mg/m²) is a standard backbone for locally advanced SCCHN, offering improved locoregional control and survival over RT alone for many sites.

High‑Yield Points - ⚡ Biggest Takeaways

• Squamous Cell Carcinoma (SCC) is the most common head and neck cancer, strongly linked to tobacco and alcohol.
• HPV infection, particularly HPV-16, is a key risk factor for oropharyngeal cancers.
• Nasopharyngeal carcinoma is associated with EBV infection and often presents with neck nodes.
• Leukoplakia and erythroplakia are critical oral premalignant lesions requiring biopsy.
• Neck node metastasis is the single most important prognostic factor in H&N SCC.
• FNAC is the initial investigation of choice for most palpable neck masses.
• Early-stage disease often involves single-modality treatment; advanced stages typically require multimodality approaches.