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INTRODUCTION

Epithelial cancers may arise from the mucosal surfaces of the head and neck including the sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. These tumors are usually squamous cell cancers. Thyroid cancer is discussed in Chap. 181.

INCIDENCE AND EPIDEMIOLOGY

About 52,000 cases are diagnosed each year and 12,000 people die from the disease. Oral cavity, oropharynx, and larynx are the most frequent sites of primary lesions in the United States; nasopharyngeal primaries are more common in the Far East and Mediterranean countries. Alcohol and tobacco (including smokeless) abuse are risk factors. Human papillomavirus (usually types 16 and 18) is associated with some of these cancers.

PATHOLOGY

Nasopharyngeal cancer in the Far East has a distinct histology, nonkeratinizing undifferentiated carcinoma with infiltrating lymphocytes called lymphoepithelioma, and a distinct etiology, Epstein-Barr virus. Squamous cell head and neck cancer may develop from premalignant lesions (erythroplakia, leukoplakia), and the histologic grade affects prognosis. Pts who have survived head and neck cancer commonly develop a second cancer of the head and neck, lung, or esophagus, presumably reflecting the exposure of the upper aerodigestive mucosa to similar carcinogenic stimuli.

GENETIC ALTERATIONS

Chromosomal deletions and mutations have been found in chromosomes 3p, 9p, 17p, and 13q; mutations in p53 have been reported. Cyclin D1 may be overexpressed. Epidermal growth factor receptor is commonly overexpressed.

CLINICAL PRESENTATION

Most occur in persons >50 years. Symptoms vary with the primary site. Nasopharynx lesions do not usually cause symptoms until late in the course and then cause unilateral serous otitis media or nasal obstruction or epistaxis. Oral cavity cancers present as nonhealing ulcers, sometimes painful. Oropharyngeal lesions also present late with sore throat or otalgia. Hoarseness may be an early sign of laryngeal cancer. Rare pts present with painless, rock-hard cervical or supraclavicular lymph node enlargement. Staging is based on size of primary tumor and involvement of lymph nodes. Distant metastases occur in <10% of pts.

TREATMENT Head and Neck Cancer

Three categories of disease are common: localized, locally or regionally advanced, and recurrent or metastatic. Localized disease occurs in about one-third of pts and is treated with curative intent by surgery or radiation therapy. Radiation therapy is preferred for localized larynx cancer to preserve organ function; surgery is used more commonly for oral cavity lesions. Overall 5-year survival is 60–90%, and most recurrences occur within 2 years. Locally advanced disease is the most common presentation (>50%). Combined-modality therapy using induction chemotherapy, then surgery followed by concomitant chemotherapy and radiation therapy, is most effective. The use of three cycles of cisplatin (75 mg/m2 IV day 1) and docetaxel (75 mg/m2 IV day 1) plus 5-fluorouracil (5FU) [750 (mg/m2)/d by 96- to 120-h continuous infusion] before or during radiation therapy is more effective than surgery plus radiation therapy, although ...

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