management of head and neck malignancies

 

Introduction

Head & neck malignancies are ofttimes labyrinthine, and argal, a pragmatic and coherent stratagem is requisite when dealing with these cases. Elucidating an apropos diagnosis and a treatment regimen heavily depends on a meticulous assessment of the patient's history, comprehensive clinical examination, and the clinician's empiricism. Enumeration of deferential diagnoses is ordinarily entrenched, while results from the biopsy and other special investigations are awaited. Numerous sanative tacks are conventionally implemented to procure the optimum possible outcome.

 

Assessment

A. History taking

The essence of gleaning an amplified patient's history yields a framework on which one may use to attain an unerringly diagnosis and treatment strategy. An imprecise interpretation engenders adjourned treatment, gratuitous testing, or misdiagnosis. Essential aspects of the anamnesis and functional history must be recorded with peculiar scrutiny given to certain imperatives that may be a risk factor or interfere with the treatment, such as, previous cancer history, smoking usance, alcohol intake, amount of sun exposure, reflux, industrial or occupational exposures, immunosuppression and prior chemotherapy (CT) or radiotherapy (RT). The asperity of the condition is established based on the duration, type, and rate of symptoms mushrooming, and physical functional deterioration perceived by the patient.

 

B. Extraoral examination

The commencement of a methodological approach to extra-oral assessment is by bilateral palpation of the head and neck (HN) with emphasis on the examination of the cervical lymph nodes, sternocleidomastoid and trapezius muscles, positioning of the windpipe, palpation of the thyroid and cricoid cartilages, hyoid bone, thyroid, parotid, and submandibular glands.

 

C. Intraoral examination

A standardized, efficient wise to intraoral examination involves visualization and feeling or percussion of the oral cavity, beginning at the lips and advancing systematically towards the oropharynx. Any portentous matter alluding the dentist to suspicion of cancer at this point should be met with an urgent referral to the head and neck surgery department, who will continue with further examination forthwith.

 

D. Radiology

A vital role in the conjecture of diagnosis, staging, and treatment of HNC is radiographic imaging. The traditional form of imaging is via computed tomography and magnetic resonance imaging. Contemporary, the use of fluorodeoxyglucose positron emission tomography (FDG PET)-CT is the recommended practice for any neoplastic lesion spreading beyond the primary site, by virtue of its sovereignty in detection, prognostication and staging malignant metastasis. Patients with high FDG aggregation have less chance of survival and should be contemplated for an exhaustive treatment protocol.

 

E. Biopsy

Utilizing liquid biopsy in the detection of HNC evidenced usefulness. The ubiquity of circulating tumor cells in metastatic lesions adumbrates poor prognosis. The histopathological lineaments and grade of cell differentiation will reflect massively on the prognosis. Ultrasound-guided core-needle biopsy and fine needle biopsy are the archetypal types of biopsy in HNC due to their immense precision rate, minuscule perils, and minimal seeding amount.

 

F. Laboratory tests

Assorted laboratory investigations such as albumin, pre-albumin, and liver function tests are essential in gauging the overall nutritional condition of the patient. Additionally, the thyroid function test and complete blood count pre and post-chemotherapy are cardinal. These tests are regularly executed for HNC patients irrespective of the treatment modality to be performed.

 

Risk Factors

The risk factors for HNC are mainly sundered into two pigeonholes:

A. Tobacco and alcohol

'Tis concrete that tobacco usance is the preeminent linchpin for oral cancer. Consumption of tobacco/betel substantiates changes in cell genes that reconcile cell division. An affiliation between tobacco compositions and mucosal cell's DNA could be the initial stage of neoplasia. In this era, the use of E-cigarettes is promoted, but there is a possible link allying them with HNC. Nonetheless, it is corroborated that the risk of developing cancer in the mouth, weasand, voice box, and pharynx are aggrandized by guzzling potations or using alcohol-containing products such as alcohol mouthwash. Tobacco intake or toping was shown to be present in 3/4 of patients diagnosed with squamous cell carcinomas of the HN, and patients using both of these carcinogenic substances together have a much higher risk of developing malignant tumors.

 

B. Other factors

Human papillomavirus (HPV) has been classified as a puissant human carcinogen. A luculent interrelation 'twixt HPV6 antibodies and increased risk of pharyngeal cancer have been documented. 25% to 70% of oropharyngeal squamous cell carcinomas are HPV related. HPV16 and HPV18 has been categorized as high menace along with other HPV types such as 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 70 while HPV 42, 43, 44 are classified as low-risk. 'Tis anticipated that HPV related oropharyngeal cancer will become the leading HPV related cancer by the year 2020, surpassing cervical cancer.

The influence of specific nutritional diet patterns has been linked with HNC. A tenacious positive relation linking high red meat intake to increased risk of HNC is chronicled. Coherently, consumption of fruits and vegetables foreshortens the risk of the oral, gullet, and pharyngeal cancer. Age is assuredly a risk factor since the mass bulk of HNC appears between the age of 50 and 60. The number of elderly patients with cancer is expected to increase in the future. In addition, miscellaneous occupational exposures lead inexorably to HNC in men and women.

 

Management

Tailoring a treatment strategy for a bewildering process as treating HNC necessitate intervention from multiple specialized conglomerates of departments such as Otolaryngology, plastic surgery, oncology, radiology, dentistry, speech pathology, nutrition, social worker physiotherapy, and an anesthetist assessment. A multi-disciplinary consultation meeting is a crucial stage in formulating the treatment plan. 'Tis ostensible that if suitable therapeutic intervention is instituted preceding the curative treatment phase, then the longterm function and quality of life (QoL) of the patient may be enhanced.

 

Head & neck surgeon and medical oncologist

The ultimate unambiguous diagnosis is contrived by the head and neck surgeon, and an unequivocal treatment modality is formulated by the treating team therewith. Generally, delineating a treatment approach pertains to TNM (tumor, lymph nodes, metastasis) staging. The systematic scheme of managing HNC inaugurates with either surgery or RT. However, synchronously administered CT and RT evinced a constructive role in treatment. Methodologically, monotherapy, which is either surgery or RT, is advocated when dealing with an early stage of cancer. Natheless, handling a progressive late stage of cancer constrain the use of combined treatment modalities such as surgery and RT with or without CT, or chemoradiotherapy without surgery as shown in Figure [1.1]

Surgery

The desideratum of the surgery is a consummate excision of the tumor with a safe margin of normal tissues. Minimally invasive surgical techniques such as trans-oral robotic surgery are more frequently adopted than the wonted open approach. Employment of surgical robots grants lesser invasive pathway and rapid functional recovery. Moreover, the enhanced recovery after surgery guidelines has dwindled the surgical complications, duration of hospital stay, and expenses. The use of prophylactic antibiotics prior to surgery is covetable. A momentous matter to heed afore proceeding with surgery is that HNC has the tendency to metastasize to cervical lymph nodes as shown in table [1.2].

 

 

Chemotherapy

The induction of CT in the treatment plan revolves around each individualized disease idiosyncrasy, the perspicacity of the treating team, and available facilities. Inauguration of CT ere RT had positive results on abating distant metastasis. Omnifarious drugs are introduced in CT such as cisplatin, carbonplatin, 5-FU, and cetuximab. Howbeit, cisplatin is perpetually used in the primary and postoperative stages of HNC. A conventional mode of treatment for a locally advanced head and neck squamous cell carcinoma (HNSCC) is by using at least 40 mg/m2 of cisplatin per sennight. Certain treatment protocols are recommended as shown in Figure [1.3]. However, a negative corollary was found when Cisplatin was used concomitantly with other drugs. Recently, immunotherapy rose as a promising treatment for metastatic HNC.

Radiotherapy

RT is comprehensively recognized as an "organ preservative" approach. It can be a substitute for surgery as it can be applied to the tumor site as well as to the lymph nodes. Although it is decorous to employ conventional RT for HNC, RT is not entirely innocuous, and certain rigorous complications transpire due to proximity of the malignancy to vital salubrious tissues. Intensity-modulated radiation therapy (IMRT) has manifested superiority when compared to conventional RT, in terms of hindering toxicity to healthy surrounding tissues, amending QoL, and ebbing away from the severity of xerostomia and weight loss. The preponderance of HNSCC is treated with IMRT integrated with concurrent systemic CT in the definitive, non-surgical, and postoperative care.

One of the laborious complications owing to RT is osteoradionecrosis (ORN). Five to ten percent of patients will develop ORN within the first 2 years of RT. Multiple correlations were apodictic ‘tween radiation dose, tobacco smoking, pre-RT tooth extraction, and the emergence of ORN. In order to minimize the risks of ORN, teeth extraction should be performed atraumatically 14 days prior to RT and radiation doses applied as low as <50 Gy. Multitudinous conservative therapeutic modalities have been introduced for low-grade ORN, such as hyperbaric oxygen therapy, antibiotic coverage, antioxidant, and antifibrotic drugs, yet the certainty behind their effect remains questionable. Notwithstanding the foregoing, the surgical approach, such as microvascular reconstructive technique, is the only solution for an advanced stage of ORN.

 

Abnormal blood count

An ineluctable fallout of CT and RT is the contraction in the number of white and red blood cells, which in return events in increased infections and anemia. Withal, hindrance of hematopoietic tissue regeneration is also prophesied, which is peradventure due to impairment of bone marrow function. Consequently, a tendency to have increased bleeding and decelerated wound healing during surgical procedures is foretold. A complete blood count is advocated 24 to 48 hours prior to any procedure that may involve bleeding.

 

Psychology

The crystal discernible depression in newly diagnosed HNSCC patients is incontrovertibly defined. The calamitous impact of depression on malnutrition and QoL is undoubtedly visualized. Additionally, a grievous strain can be augmented in the patient's mind due to fear of disease recurrence. Psychological screening, monitoring, documentation, and treatment should advent at the initial visit and continue at pertinent intervals thereafter. The psychological intervention aims to enhance the patient's knowledge, positive behavior, and mind-set. Premature apprehension and treatment of mental perplexities may temper QoL in cancer patients.

 

Curtailment of risk factors

Failure to cease the use of tobacco has demonstrated a decline in the overall survival rate of HNC patients. Moreover, the persistent usage of such carcinogenic products has shown to be linked to an increased prevalence of late toxicity. The conspicuous significance of educating the patient on the risks of smoking and the utmost need for this to be discontinued should be transparent to the patient. Alcohol cessation of 20 years or more brings down the patients’ risk of developing HNC to the same level of risk as a patient who has been alcohol-free their whole life.

 

Speech and language pathologist (SLP)

The aptness to swallow before HNC treatment is firmly connected to the long-term ability to swallow. Generally, a reduction in oral function is expected three to four weeks after treatment. For this reason, fostering of SLP in rehabilitation afore cancer treatment is vastly recommended. In the inaugural stage, SLP will cater the patient with appropriate strategies and exercises to surmount foreseeable swallowing impediments. The employment of these instructions will promote rectification in dysphagia, specifically in HNC patients. Also, as postoperative trismus is anticipated, specific stretching exercise techniques may be helpful. Significant advancements in patients' speech and swallowing functions were displayed post-speech and language therapy.

 

Anaesthetist assessment

The pivotal task of the anaesthetist in the evaluation prior to the operation encompasses various fundamental attributes such as acknowledgment of any airway obstructions, recognition of all the risks related to the procedure, and other medical conditions that the patient has and to ultimately formulate an impeccable blueprint for peri-operative care.

 

Dietician

Cachexia is mundane in cancer patients, particularly during CT, and argal, early intervention is indispensable. Difficulty eating may continue long after the treatment, and respectively, weight loss is augured. The involvement of a dietician is hence necessary. Regular Individualized dietary counseling sessions have shown to be fruitful in terms of weight maintenance. During the convalescent period, patients will endeavor to adapt to new living arrangements by implementing different techniques to assist them with meal times and refine their social ability. High energy nutritional diet of 35kcal per kg with close monitoring of weight is advocated for patients undergoing radio/chemotherapy.

 

Dentist

Convoluted dental complications ensue due to the treatment of HNC, especially with CT and RT, as presented in figure [1.4]. A thorough dental screening is performed prior to the start of cancer treatment, and a dental treatment plan is formulated in conjunction with the oncology team and executed accordingly. Moreover, a multidisciplinary team of different dental specialties is required for these cases. Reasonable systematic oral care regimens are implemented to mitigate complications and boost QoL. Further magnification on treatment options is delineated in table [1.5].

 

 

Physiotherapy

A hodgepodge of intricate physical conundrums evolves in the terminal phase of cancer. Professional interference is hence essential, especially in palliative care. Strenuous effort is invested by physiotherapists to scale down the level of pain, expedite healing, facilitate muscle movement and pare injuries, infections, and abominable complications. Correspondingly, an individualized exercise regime, is codified for each patient. The pace magnitude of physical rehabilitation is contingent on the patient's prognosis for recuperation. The patient's level of function and standards of life have shown to ameliorate by participating in an eleven-week scrupulous physical activity program.

 

Plastic Surgery

Scars and defects are orthodox concomitants to HNC treatment. The eventual guise of the patient hinges enormously on the dexterity of the surgeon. Ergo, sundry of departments such as plastic surgery, dermatology, and otolaryngology sake to restore aesthetics and mayhap function, particularly in palliative care. Interpolation of facial prosthetics is a viable surrogate whenever surgery is undesirable and had shown a prolonged positive impact on QoL, as displayed in the pictures alow.

 

Specialist nurse

The role of a specialist nurse in post-operative follow up, and rehabilitation for every HNC patient cannot be overemphasized. Embracement of such a specialty has manifested substantial progress in various aspects related to care. The continuous supportive care provided by a specialist nurse is essential for perplexed case management.

 

Palliative care

The objectives of the rehabilitation process under palliative care, are to support patients with mental, social, and spiritual pressure, as well as reducing physical pain. Disparate palliative surgical modi operandi can be enforced to restrain bleeding, odor, and infections. Additionally, RT is a potent method for diminishing fardel focal symptoms and should be used for a reasonably short amount of time in a precisely measured high doses whilst ensuring effectiveness. Vital communication and management skills should be consolidated into all specialties involved in the treatment plan. Assorted drugs such as capecitabine have been acquainted as a palliative care method in advanced HNSCC. Phone communication betwixt patients and palliative care specialty services evidenced betterment in patient's QoL and frame of mind. Similarly, early intervention of palliative care in terminal stage cancer patients had a positive sequel on QoL and subsided profound psychological sadness.

 

Follow up

Post cancer treatment follow-ups are advocated, especially during the first 2 years, and should continue for at least 5 years thereon. The multidisciplinary team appointments are the cornerstone of an optimized rehabilitation process, which is achieved by early detection of recurrence, toxicity assessment, reduction of teen level, physical examination, nutritional, and emotional support. Furthermore, additional financial, emotional, and social support can be provided to the patient via cancer charity organizations such as Macmillan Cancer Support.

 

Survival & Quality of life

Generally, the rate of survival in HNC patients is upturning. However, impeded diagnosis of metastatic HNSCC will have a dreadful prognosis and is expected to have a median survival time of 10 months. Gender, marital status, race, lymph nodes involvement, the timing of treatment, and many other factors contribute to the overall survival. Controversially, the upsurge in survival rate may not be of great value if the patient was not ameliorating from medical intervention in terms of symptoms pruning and boosting QoL. In addition, a steep decline in the QoL is noted just after the treatment without any discrepancy in relation to the age group. Despite the significant advancement in the treatment of HNSCC over the last few decades, the QoL has not considerably revamped.

 

Conclusion

The pilgrimage of head & neck cancer bequeaths prolonged ramifications on the social, psychological, and physiological aspects of life. An amalgamation of copious factors contributes to the impact on the quality of life. Envisaging the aftermath of the treatment is not entirely achievable, and plenary reinvigoration is seldom. Hence, the interminable amount of succour given to the patient is the stanchion to a marginally improved outcome.

Plenitude of resources are currently dissipated on inefficacious researches, whereas only a modicum is used on early detection and prevention. Conceivably, a regular screening programme would constringe the overall tale of mortality. Heretofore, the definitive remedy to this malady remains enigmatic, and that is the melancholic denouement of the story. In the interim, the vital role of healthcare professionals is patients’ education on predisposing risk factors, as fundamentally, prevention is better than cure.