Department of Hemato-Oncology MGR review

 Epithelial carcinoma of the head and neck  arised from the mucosal surfaces in the head and meck area  squamous cell in origin  Paranasal sinuses, the oral cavity, and the nasopharynx, oropharynx, hypopharynx, and larynx

 The number of new cases of head and neck cancers in the United States was 40,500 in 2006  accounting for about 3% of adult malignancies  The worldwide incidence exceeds half a million cases annually  Peak incidence occurs between 55 and 65 years of age  Three times more common in men than in women  In North America and Europe  the tumors usually arise from the oral cavity, oropharynx, or larynx  nasopharyngeal cancer is more common in the Mediterranean countries and in the Far East

 Alcohol and tobacco use are the most common risk factors  marijuana and occupational exposures such as nickel refining, exposure to textile fibers, and woodworking  Dietary factors  lowest consumption of fruits and vegetables  consumption of salted fish  Viral etiology  Epstein-Barr virus (EBV) infection  human papillomavirus (HPV)

 located behind the nose just above the mouth and throat  a hollow tube about 5 inches long that starts behind the nose and goes down to the neck and ends at the top of the trachea

 Epidermiology  Worldwide, there are 80,000 incident cases and 50,000 deaths annually  Geographic and ethnic distribution  an incidence of 0.5 to 2 per 100,000 in the United States and Western Europe  the incidence may reach 25 cases per 100,000 in southern China, including Hong Kong  Populations that migrate from high to low risk areas retain an elevated risk, though this risk typically diminishes in successive generations

 patients may remain asymptomatic for a prolonged period  frequently originates from the pharyngeal recess : clinically occult site  The most common presenting complaints  headache (related to cranial nerve involvement)  a mass in the neck (representing cervical node metastases)  The clinical triad of a neck mass, nasal obstruction with epistaxis, and serous otitis media occurs infrequently

Nasopharyngeal carcinoma-presenting symptoms and duration before diagnosis HKMJ Vol 3 No 4 December 1997

Nasopharyngeal carcinoma-presenting symptoms and duration before diagnosis HKMJ Vol 3 No 4 December 1997

 Nasopharyngeal cancers are categorized into three histologic subtypes by the WHO  Keratinizing squamous cell carcinoma (WHO I)  Represents about 5% worldwide  15~25%of all nasopharyngeal cancers in north america  Associated with traditional risk factors such as smoking  Nonkeratinizing carcinoma: differentiated (WHO Type II) and undifferentiated (WHO Type III)  Latently infected with EBV in 95% of cases  Represent the majority of cases in north america and worldwide  Basaloid squamous cell carcinoma

 Physical examination  Inspection of all visible mucosal surfaces  Palpation of the floor of mouth and tongue and of the neck  All visible or palpable lesions should be biopsied  CT scan  From the base of the skull to the clavicles  MRI  Evaluating soft tissue involvenemt  Chest radiography and bone scan  To screen for distant metastases  Endoscopic examination  Laryngoscopy, esophagoscopy, bronchoscopy  Identify any additional premalignant lesions or second primaries

 Localized disease  T1 or T2 (stage I or stage II) lesions without detectable lymph node involvement or distant metastases  single modality RT with good locoregional control and survival  Five-year overall survival rates of 90 percent for stage I and 84 percent for stage II have been reported

 Locally or regionally advanced disease  Combined modality therapy including surgery, radiation therapy, and chemotherapy  Concomitant chemotherapy and radiation therapy appears to be the most effective approach

 Induction chemotherapy  patients receive chemotherapy before radiation therapy  drug combinations including cisplatin, 5-FU, and a taxane  Concomitant chemoradiotherapy  killing radiation-resistant cancer cells with chemotherapy  chemotherapy can enhance cell killing by radiation therapy  improvement in 5-year survival of 8% with concomitant chemotherapy and radiation therapy  Five-year survival is 34–50%  The use of radiation therapy together with cisplatin has produced markedly improved survival in patients with advanced nasopharyngeal cancer  Monoclonal antibody to the EGFR (cetuximab) increases survival rates when administered during radiotherapy

HEAD AND NECK CANCER N Engl J Med, Vol. 345, No. 26 · December 27, 2001

 Recurrent and/or metastatic disease  Ten percent of patients present with metastatic disease  over half of patients with locoregionally advanced disease have recurrence  treated with palliative intent  Response rates to chemotherapy average only 30–50%  the duration of response averages only 3 months  the median survival time is 6–8 months  Combinations of cisplatin with 5-FU, carboplatin with 5- FU, and cisplatin or carboplatin with paclitaxel or docetaxel are frequently used  EGFR-directed therapies, including monoclonal antibodies (e.g., cetuximab) and tyrosine kinase inhibitors (TKI) of the EGFR signaling pathway (e.g., erlotinib or gefitinib) have single-agent activity of approximately 10%

Recent Advances in Head and Neck Cancer N Engl J Med, Vol. 359, No. 11 september 11, 2008