The most common localization of head and neck cancer

Head and neck cancer develop each year with nearly 60,000 people in the US. With the exception of skin and thyroid cancer is in head and neck tumors in> 90% of cases squamous or Epidermoidkarzinome; most others are adenocarcinomas, sarcomas and lymphomas. The most common localization of head and neck cancer larynx (including supraglottis, glottis and subglottis) oral cavity (tongue, floor of the mouth, hard palate, buccal mucosa and alveolar ridges) oropharynx (base of the tongue, tonsils and soft palate) Less common locations include the nasopharynx, nasal cavity and the sinuses, hypopharynx and the salivary glands. Further discussions regarding other sites of head and neck tumors are found elsewhere in the Merck Manual: Intracranial tumors in adults intracranial Tumpren in children Malignant tumors of the thyroid tumors of the orbit and cancers that affect the retina acoustic skin cancer, the incidence of head and neck cancer increases with age. Although most patients are 50-70 years old, the incidence is increasing in younger patients. Head and neck cancers occur in men more often than women; However, the incidence varies by gender in terms of anatomical localization and has changed due to the rising number of women smokers. Etiology The vast majority of patients (85% or more) with head and neck tumors are found in the history of alcohol and / or smoking. People who consume a lot of tobacco and alcohol over a long period, have a 40-fold increased risk of developing squamous cell carcinoma. Also, snuff or chewing tobacco, exposure to sunlight, former Röntgenunteruchungen of head and neck, certain viral infections, poorly fitting dentures, chronic candidiasis (oral thrush), and poor oral hygiene are suspected as possible risk factors. That oral cancer mainly in India is widespread, could the chewing Betelpfriemen (or “paan” said mixture) are related. Main causes of squamous cell carcinoma of the lower lip are long-term sun exposure and tobacco use. A thyroid carcinoma and benign or malignant salivary gland tumors particularly patients are predisposed which were previously irradiated for acne, and patients with increased facial hair, Thymusvergrößerung, hypertrophic tonsils or adenoids. The Epstein-Barr virus plays a role in the pathogenesis of nasopharyngeal carcinoma, and serum measurements of specific Epstein-Barr virus proteins can act as biomarkers for disease recurrence. The relationship between infection with the human papillomavirus (HPV) and squamous cell carcinoma of the head and neck, particularly oropharyngeal cancer is well documented. The rise of HPV-associated cancer has caused an overall increase in the incidence of oropharyngeal cancer, would have been otherwise expected for the result of the decrease in smoking rates over the past two decades a decline. The mechanism of viral mediated tumorigenesis appears to be different from the tobacco-mediated. Symptoms and signs The clinical picture of head and neck cancer is highly dependent on the location and extent of the tumor from. Common initial manifestations of head and neck tumors include asymptomatic lesions in the throat, painful mucosal ulceration, visible mucosal lesions (e.g., as leukoplakia, erythroplakia), hoarseness, and dysphagia. Depending on the location and growth of a tumor is pain, paresthesia, nerve paralysis, trismus and bad breath can then set. Earaches are an often overlooked symptom that usually stands for pain radiating the primary tumor. Weight loss, caused by eating disorders and odynophagia is also common. Diagnosis Clinical evaluation biopsy Imaging tests and endoscopy to clarify the extent of the disease, the best cancer screening method are routine physical examinations (including thorough inspection mouth) before symptoms appear. Commercially available brush biopsy kits help in the investigation on oral cancers. Each head and neck symptom (eg. As sore throat, hoarseness, earache), which persists> 2-3 weeks, should arrange for a referral to a specialist that performs a flexible fiber-optic laryngoscopy for the evaluation of the larynx and pharynx generally. A definitive diagnosis requires a biopsy evaluation generally. A fine needle aspiration is used for a mass of the neck; it is well tolerated, accurate and, unlike an open biopsy no impact on future treatment options. Oral lesions are evaluated with an incisional biopsy or a brush biopsy. Nasopharyngeal, oropharyngeal or laryngeal lesions biopsied by endoscopy. Imaging techniques (CT, MRI or PET / CT) can be performed to help assess the extent of the primary tumor, the involvement of neighboring structures and spread to the cervical lymph nodes. Tumor staging Staging (staging) of head and neck tumors (see Table: Staging of head and neck tumors) depends on the size and location of the primary tumor (T), number and size of cervical lymph node metastasis (N) as well as existing distant metastases (M). A necessary prerequisite for tumor staging are mostly imaging techniques such as CT and / or MRI and PET often. Staging of head and neck cancer tumor stage (maximum penetration) Regional lymph node metastasis Distant metastasis I T1 N0 M0 II T2 N0 M0 III or T3 N0 M0 T1-3 N1 M0 IVA T1-3 N2 M0 T4a N0-2 M0 IVB T4b Any N M0 Any T N3 M0 IVC Each T Any N M1 TNM classification: T1 ? 2 cm in greatest dimension; T2 = 2-4 cm or infestation of 2 areas of specific localization; T3> 4 cm or infestation of areas 3 of specific localization; T4 = Invasion of specific structures (4a is a moderately advanced local disease and 4b is a highly advanced local disease). N0 = no lymph node involvement (LK); N1 = 1 LK ? 3 cm; N2 = LK of 3-6 cm or more nodes; N3 = LK> 6 cm. M0 = no distant metastases; M1 = existing distant metastases. Prognosis The prognosis for head and neck cancer varies greatly depending on the tumor size, the primary isolation, the etiology and the presence of regional or distal metastasis. In general, the prognosis of early diagnosis and timely treatment initiation with suitable means is favorable. Head and neck cancers occur locally on and then metastasize to regional cervical lymph nodes. The distribution in the regional lymphatics is partly due to the tumor size, its extent and its aggressiveness and reduced overall survival by nearly half. Distant metastases (most commonly in the lungs) often occur later, usually in patients with advanced tumor stages. Distant metastases reduce survival considerably and are almost always incurable. An advanced local disease (a criterion for the advanced T stage) with an invasion of muscle, bone or cartilage also reduced the cure rate significantly. Perineural spread, which shows up in pain, paralysis or numbness, indicates a very aggressive tumor associated with lymph node metastasis and a worse prognosis than a similar lesion without perineural invasion. With the right therapy can be used in Stage I 5-year survival rates of 90% are achieved in stage II of 75-80% in stage III of 45-75% and in some cancer stages IV up to 50%. The survival rates vary greatly depending on the primary localization and aetiology. Throat cancer in stage I has an excellent survival rate when compared to other locations. By HPV induced Oropharyngealkrebs a much better prognosis seems to have as Oropharyngealkrebs, caused by tobacco or alcohol. Since the forecasts of HPV-positive and HPV-negative Oropharyngealkrebs different, all tumors of the oropharynx should be routinely tested for HPV. Therapy surgery and / or radiotherapy occasionally chemotherapy The main treatment measures for head and neck cancer are surgery and radiation treatment. These modalities can be used alone or in combination as well as with or without chemotherapy. However, chemotherapy is almost never used as a primary treatment for healing. Many tumors speak about equally well to surgery or radiation therapy to at independently of the location, which is why the choice of therapy other factors (eg. As patient preference) or localization-specific morbidity can be decisive. However, there is a clear superiority of one modality for specific locations. For example, surgery is more suitable for disease in early stages that occur in the oral cavity, since the radiation can cause mandibular ORN. Endoscopic surgery is used more and more frequently; at selected head and neck tumors showing cure rates that are comparable to those with open surgery or irradiation, with its morbidity is significantly lower. Endoscopic approaches are most commonly used for laryngeal surgery and usually a laser is used to make the cuts. If the decision is for a radiation therapy as the primary therapy, the primary tumor and cervical lymph nodes are – sometimes on both sides – irradiated. The treatment of the lymphatic vessels, either by radiation or surgery, histological criteria and the risk of lymph node metastasis is the primary localization is determined. Lesions in the early stages often do not require treatment of the lymph nodes, while this is the case in advanced lesions. Head and neck locations that are rich in lymphatic vessels (eg. As the oropharynx, supraglottis) regardless of tumor stage require irradiation of the lymph nodes in the rule, while locations with fewer lymph vessels (eg. B. larynx) for diseases at an early stage in usually do not require irradiation of the lymph nodes. The intensity-modulated radiation therapy (IMRT) transmits the radiation to a very specific area, potentially reducing negative side effects without compromising tumor control. The advanced disease (stage III and IV) often requires a multimodality treatment including chemotherapy of combination therapy, radiation therapy and surgery. The invasion of bone or cartilage makes surgical resection of the primary tumor and usually also the regional lymph nodes is required because of the high risk of spreading via the lymphatic system. If the primary localization is treated with surgery, followed by postoperative irradiation of the lymph nodes, if high-risk features such. As several of cancer, there are involved lymph nodes or extracapsular extension. Since irradiated tissue heals worse postoperative preoperative radiation therapy is preferred. Recent studies have shown that additional chemotherapy in addition to adjuvant radiation of the neck improves the regional cancer control and survival. However, this approach causes significant adverse side effects, such as increased dysphagia and bone marrow suppression; Therefore, the decision to additional chemotherapy should be carefully considered. An advanced squamous without bony invasion is often treated with concurrent chemotherapy and radiotherapy. Although recommended as organ gently, the combined radiation chemotherapy doubled the acute toxicity rate, especially for severe dysphagia. Radiation therapy alone can be used in debilitated patients with advanced disease who can not tolerate the side-effects of chemotherapy and have too high a risk for general anesthesia. A primary chemotherapy remains chemosensitive tumors such as Burkitt’s lymphoma or patients with extensive metastatic disease (z. B. liver or lung infection) reserved. Palliative treatment of pain or shrink tumors in patients that can not be treated with other methods, to drugs such as cisplatin, fluorouracil, bleomycin, and methotrexate are suitable. The response may initially be good, but it is not permanent, and the cancer almost always returns. Because the treatment of head and neck cancer is so complex a multidisciplinary treatment planning is essential. Ideally, each patient should be discussed by an expert team, which is composed of representatives of all disciplines treated together with radiologists and pathologists, so unity hinsichtlicher the best treatment is achieved. Once a treatment is selected, it is best coordinated by a team consisting of surgical and reconstructive surgeons, radiation and medical oncologists, speech and language pathologists, dentists and nutritionists. Plastic and reconstructive surgeons play an increasingly important role, as the use of free tissue transfer flaps allows the functional and cosmetic reconstruction of defects, making the quality of life of the patient by a process that caused significant morbidity previously, is significantly improved. Common donor sites, which are used for reconstruction, include the fibula (often used to reconstruct the mandible), the radial arm (usually for the tongue and the floor of the mouth is used) and the front lateral thigh (often for a larynx or pharynx reconstruction used). The treatment of recurrences The management of recurrent tumors after therapy is complex and shows potential complications. A palpable swelling or ulcerated (edematous or painful) lesion that forms at the site of the primary tumor after treatment, is highly suspicious to a residual tumor. In these patients (thin-film) CT or MRI scan for clarification is required. If recurrences occur after surgery, even all the scars layers and flaps must be cut in addition to the residual tumor. While radio and / or chemotherapy may be used, but often have limited success. In recurrences after radiation therapy, patients should best be operated on. However, some patients may benefit from additional radiotherapy; but this approach has a high risk of side effects and should be done with care werden.Symptomkontrolle pain is a common symptom in patients with head and neck tumors and must be given due consideration. A palliative surgery or irradiation may cause temporary pain relief, and in 30-50% of patients, the state of recovery after chemotherapy holds an average of 3 months. A step by step approach in pain management, as recommended by the WHO, is crucial for pain control. Severe pain can be best in conjunction with a pain therapist and a palliative treatment. The decisive factor is adequate symptomatic treatment of pain, Essschwierigkeiten, the Würgereizes by secretions and other problems. It should also be clarified in advance where the care measures the patient’s wish (advance directives) .Nebenwirkungen All cancer treatments have potential complications and expectable consequences. Since many treatments show similar healing rates, the choice of treatment modality is largely based on real or perceived differences in the sequelae. Although it is generally believed that surgical procedures cause the highest morbidity, many procedures can be performed without affecting the appearance or function significantly. Increasingly complex reconstructive procedures and techniques, including dentures, implants, stalked regional and complex free flaps, function and appearance can often restore the normal state to close. As toxic side effects of chemotherapy malaise, severe nausea and vomiting, mucositis, temporary hair loss, gastroenteritis, Hämatopoesestörungen, immune suppression and infection can occur. A therapeutic irradiation of head and neck tumors has several side effects: At a dose of 40 Gy the function of all salivary glands located in the beam path is permanently damaged, resulting in xerostomia (dry mouth) with a significantly increased risk of tooth decay has resulted. Newer radiation techniques such as intensity modulated radiation therapy (IMRT) can minimize or eliminate toxic doses to the parotid gland in certain patients. Because doses> 60 Gy affect the blood supply of bone, especially the lower jaw, an ORN may develop (Dental care of patients with systemic diseases: radiotherapy). Under the circumstances, there is a risk that softened bones and connective tissues break after a tooth extraction. Therefore, dental procedures (teeth cleaning, fillings and extractions) should be completed before radiotherapy. If teeth are beyond redemption because of their poor condition, they should be held. Radiation therapy can (sometimes dermatitis, with transition to a dermatofibrosis) also lead to inflammation of the mouth (oral mucositis) and the overlying skin. Also, loss of taste (ageusia) and smell disorders (Dysosmie) often occur, but are usually temporary. Crucial prevention is the elimination of risk factors. All patients should stop smoking and limit your alcohol consumption. The elimination of risk factors helps cancer patients also helps prevent tumor recurrence after treatment. A new primary tumor develops in about 5% of patients / year (at maximum risk at about 20%); the risk is lower among those who set the tobacco consumption. Current HPV vaccines are effective against some of the HPV strains that cause Oropharyngealkrebs, making the incidence of this cancer should be reduced by a current recommended vaccination in childhood. By sunscreens and nicotine abstinence, a lower lip cancer can be prevented. Since 60% of head and neck tumors are quite advanced at diagnosis (stage III or IV), thorough, regular examination of the upper aerodigestive tract is to reduce the most promising strategy, morbidity and mortality.


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