AAO-HNSF Primary Care Otolaryngology Handbook

HEAD AND NECK CANCER

tumors involving vital structures with no clear margination in the soft tissues of the neck. HPV-associated cancers have a separate staging system in the American Joint Committee on Cancer version VIII, which reflects a prognosis that is better than non-HPV HNC with similar primary tumor size and metastatic disease. Cancers of the larynx, partic- ularly glottic cancer, are usually smaller at presentation because of the relatively quick onset of symptoms (hoarseness), and a different staging system is used. Patients with small or early tumors without metastases typically do well (Figure 15.4), whereas those with large or metastatic tumors tend to do poorly. Unfortunately, however, 60–75 percent of HNC patients do not present until the tumor is at an advanced stage.

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In general, T1 and T2 cancers respond well to surgery or radiation therapy (75–80 percent five-year survival). For larger or metastatic lesions, surgery, radiation therapy, and, in some instances, chemotherapy are often recom- mended, and the prognosis is poorer (15–35 percent five-year survival). In addition, chemo- therapy potentiates the effects of radiation, and has become an important adjunct in the treat- ment of HNC. For HPV-associated HNC, even with advanced presentation, the prognosis is very good (80–90 percent five-year survival). When HNC patients receive radiation therapy as part of their treatment, it is usually given once a day for six to seven weeks, although some physi- cians use twice daily (hyperfractionated) proto-

Figure 15.4. Early squamous cell cancer of the right vocal fold arising in a smoker. This patient presented with voice change and hoarseness. Early detection and appropriate treatment provide the greatest opportunity for cure in these individuals.

cols. It is generally felt that 6000 rads or centigray (cGy) is a minimum dose for a neck with microscopic disease. If there is bulky neck metas- tasis, the dose may go up to 7000 cGy. Radioactive implants using a cesium source ( brachytherapy ) may be placed to deliver a very high, localized dose to a superficial tumor. There are acute and late effects of radiation therapy, including mucositis and xerostomia by way of destruction of the major and minor salivary glands’ ability to produce saliva. Since teeth remineralize with the minerals in saliva, they are very prone to decay during and after this therapy. If a patient has teeth in very poor condition, all the teeth should be extracted before the patient begins radiation therapy.

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