Current Issues in Cancer: Cancer of the head and neck

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Abstract
Clinical presentation and pathology Apart from squamous cell and undifferentiated carcinomas, other fairly common tumour types include lymphoma and adenoid cystic carcinoma, both more common in oral and pharyngeal sites than in the larynx. Head and neck lymphoma seems to be occurring more frequently, possibly as a result of AIDS, transplant operations, and other instances in which there is immunodeficiency. Salivary gland tumours are generally considered separately from other head and neck tumours and the histological variety is considerable, though the commonest tumour remains the typically benign pleomorphic adenoma. Though no staging system is entirely satisfactory, The TNM system has gained wide acceptance (box). The system is complicated by the fact that tumour (T) stage has different specifications for each primary site, though the N (nodal disease) and M (metastatic disease) designations are standard. The probability of spread to lymph nodes in the neck is highly dependent on the primary tumour site. Nasopharyngeal carcinomas, supraglottic (as distinct from glottic) laryngeal tumours, floor of mouth tumours, and disease in oropharyngeal and hypopharyngeal sites have very high rates of spread. View this table: In this window In a new window TNM and clinical staging of head and neck cancer (American Joint Committee on Cancer Staging) Patients frequently present not with symptoms of the primary disease but with the neck node meta-stases. This is of great diagnostic importance, as diseases such as carcinoma of the bronchus, Hodgkin's disease, and non- Hodgkin's lymphoma may also present in this way. The precise site of the node metastases in the neck may give important clues to the likely primary tumour (fig 2). Involved upper cervical lymph nodes are more likely to be due to supraglottic laryngeal carcinoma or a tumour of the oropharynx, whereas enlarged nodes in the submandibular or lower cervical area are more likely to be due to a carcinoma of the tongue or floor of the mouth. An involved node deeply situated in the supraclavicular fossa may be due to a gastric carcinoma or a carcinoma of the bronchus or thyroid. A tendency to ulcerate makes the diagnosis more likely to be a squamous cell carcinoma than, for instance, a lymphoma. Bulky bilateral neck disease, particularly in a young person and without any obvious primary site within the head and neck, is more likely to be due to lymphoma than carcinoma. In histologically doubtful cases the advent of sensitive immunocyto-chemical staining has led to much greater confidence in tumour classification. View larger version: In this window In a new window Fig 2 Relation of diseased lymph nodes in neck to primary sites of cancer. (From Tobias and Williams23 Lymph node metastases in the neck carry considerable prognostic weight. In particular, the presence of large or fixed (N3) node disease almost always renders the patient incurable by surgery, with only a faint hope of cure by non-surgical means. Fine needle aspiration cytology of suspicious nodes is important in order to confirm the tumour stage and tailor treatment accordingly. Open biopsy of suspicious lymph nodes is occasionally necessary.