HEAD AND NECK CANCERS
( By JASCAP )

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Symptoms and diagnosis

Symptoms of head and neck cancers

The symptoms of head and neck cancers will depend upon where it is - for example, cancer of the tongue may cause some slurring of speech.

The most common symptoms of a cancer of the head and neck include:

  • an ulcer in the mouth that doesn't heal within a few weeks
  • difficulty in swallowing, or pain when chewing or swallowing
  • trouble with speaking or breathing, such as a hoarse voice or persistent noisy breathing
  • a constant sore throat and earache affecting one side
  • a swelling or lump in the mouth or neck.

Less common symptoms include:

  • a numb feeling in the mouth or on the lips
  • an unexplained loose tooth
  • a persistent blocked nose or nosebleeds
  • ringing in the ear or difficulty hearing
  • pain in the face or upper jaw
  • pre-cancerous changes in the lining of the mouth or on the tongue, which can appear as persistent white patches (leukoplakia) or red patches (erythroplakia) - they are usually painless but can sometimes be sore and may bleed.

Although these symptoms can be caused by conditions other than cancer, it's important that they are always checked out by your doctor or dentist, particularly if they persist.

Lymph nodes

An important common symptom of head and neck cancer is swelling of one or more of the lymph nodes in the neck.

The lymph nodes (also known as lymph glands) form part of the lymphatic system, which is the body's natural defence against infection. They contain white blood cells that help to fight infection and disease. Lymph nodes occur throughout the body but can sometimes be felt as tiny pea-sized lumps in the neck, under the armpits and in the groin.

Diagram of the lymphatic system in the upper body

Cancers in any part of the body can spread into nearby lymph nodes. This is particularly common with head and neck cancers, where the lymph nodes in the neck can become enlarged. Sometimes the first symptom of a head and neck cancer will be a painless enlargement of one of these lymph nodes.

Enlarged lymph nodes are much more likely to be due to a harmless infection than to cancer. However, if a lump stays for more than 3-4 weeks, despite a course of antibiotics, it should be examined by a specialist.

How head and neck cancers are diagnosed

Your GP or dentist will refer you to hospital for specialist advice, tests and treatment. You are likely to see an oral and maxillofacial surgeon (who is qualified as a dentist and a doctor) or an ear, nose and throat (ENT) specialist.

At the hospital

At the hospital, the specialist will ask you about your current symptoms as well as your medical history, and will want to know if you are taking any medicines. The doctor will then examine your mouth, throat and neck.

Nasendoscopy

In order to examine your throat and neck, the doctor may use a small mirror held at the back of your mouth. The doctor may also pass a nasendoscope (a very thin flexible tube with a light at the end) into your nose to get a better view of the back of the mouth and throat.

These tests can be uncomfortable, but will only last a few minutes. You may be given a lozenge to suck which contains a local anaesthetic that numbs the mouth, or the area may be sprayed with an anaesthetic spray which numbs the back of your throat. If you do have a local anaesthetic, you shouldn't eat or drink anything for about an hour afterwards, until your throat has lost the numb feeling. This is because there's a risk of things going into your windpipe when you swallow. You could also burn your mouth or throat with hot drinks.

Biopsy

The doctor can only make a definite diagnosis by taking a sample of cells from the abnormal area to examine under a microscope. This procedure is called a biopsy.

Sometimes the biopsy can be taken in the clinic. The affected area is first numbed with some local anaesthetic. A small piece of the suspected cancer is then removed using a very fine needle or a special pair of tweezers (biopsy forceps).

However, it is more likely that a biopsy will be taken while you are asleep under a general anaesthetic. This allows the specialist to examine the mouth and throat area closely and take biopsies from any other suspicious areas. Usually this is done during a day visit, but you may need to spend a night in hospital.

A specialist doctor, known as a pathologist, will look at the sample of cells under the microscope. They will be able to tell if cancer cells are present and find out what type of cancer it is.

Fine needle aspiration cytology (FNAC)

This is a quick, simple procedure that is done in the outpatient clinic. Using a fine needle and syringe, the doctor takes a sample of cells from a lump and sends it to the laboratory to see if any cancer cells are present. An FNAC may be quite uncomfortable and the area may be bruised for a week or so afterwards.

Microcytoscopy

This is a new test that is still being evaluated in research. It is sometimes used for people with pre-cancerous conditions who need to have regular biopsies. Instead of having biopsies, a small amount of blue dye is painted onto the abnormal area, which is then looked at very closely using a microscope. Microcytoscopy should not be painful although it may be a little uncomfortable.

Staging of head and neck cancers

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment.

A common way of staging head and neck cancers is the TNM staging system.

T describes the size of the tumour and whether it has begun to spread to nearby structures, such as the skin or muscle.

N describes whether the cancer has spread to the lymph nodes.

M describes whether the cancer has spread to another part of the body (secondary or metastatic cancer).

The staging of the different types of head and neck cancers are all slightly different. Your doctor or nurse can give you more details about the stage of your cancer.

Grading

Grading refers to the appearance of the cancer cells under the microscope. The grade gives an idea of how quickly the cancer may develop. Squamous cell cancers of the head and neck are graded from 1-3.

Low-grade or grade 1 means that the cancer cells look very like normal cells in the head and neck area.

In high-grade or grade 3 cancers the cells look very abnormal and are more likely to spread.

Moderate-grade or grade 2 cancers fall between these two grades and have a level of activity somewhere between.

Further tests for head and neck cancers

If the biopsy result shows that you have cancer, your doctor may want to do some further tests to find out more about your cancer. These tests help the doctor gather as much information as possible, so they can decide which is the best type of treatment for you.

Your doctor will decide which particular tests are necessary in your case. These may include some of the following:

X-ray

The doctor may want to take x-rays of your face or neck to see whether any bones have been affected. An x-ray known as an orthopantomogram (OPG) may be taken to look at your jaw and teeth.

You may have a chest x-ray to check your general health and to see whether the cancer has spread to the lungs. It is very rare for head and neck cancers to spread beyond the head and neck area, but if they do it's usually to the lungs.

CT (computerised tomography) scan

A CT scan is a series of x-rays, which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes from 10-30 minutes. CT scans use a small amount of radiation, which will be very unlikely to harm you and will not harm anyone you come into contact with.

You will be asked not to eat or drink for at least four hours before the scan.

Having a CT scan

You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it's important to let your doctor know beforehand.

You will probably be able to go home as soon as the scan is over.

MRI (magnetic resonance imaging) scan

This test is similar to a CT scan but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. Before the scan you may be asked to complete and sign a checklist. This is to make sure that it's safe for you to have an

MRI scan because the scanner is a powerful magnet. The checklist asks about any metal implants you may have, for example a pacemaker, surgical clips or bone pins.

You should also tell your doctor if you have ever worked with metal or in the metal industry, as very tiny fragments of metal can sometimes lodge in the body. If you do have any metal in your body it's likely that you won't be able to have an MRI scan. In this situation another type of scan can be used.

Before having the scan, you'll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm, which doesn't usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly.

During the test you'll be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It's painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It's also noisy, but you'll be given earplugs or headphones. You will be able to hear, and speak to, the person operating the scanner.

PET (positron emission tomography) scan

PET scans are a newer type of scan and you may have to travel to a specialist centre to have one. They are not always necessary but you can discuss with your doctor whether one would be useful in your case. PET scans can be used to find out whether a head and neck cancer has spread beyond the original site, or to examine any lumps that remain after treatment to see whether they are scar tissue or whether cancer cells are still present.

A PET scan uses low-dose radioactive glucose (a type of sugar) to measure the activity of cells in different parts of the body. A very small amount of a mildly radioactive substance is injected into a vein, usually in your arm. A scan is then taken a couple of hours later. Areas of cancer are usually more active than surrounding tissue and show up on the scan.

PET/CT scan

The scan is a combination of a CT scan which takes a series of x-rays to build up a three-dimensional picture (see above) with a PET scan which uses low dose radiation to measure the activity of cells in different parts of the body (see above). This gives more detailed information about the part of the body being scanned. PET/CT scans are a new type of scan and you may have to travel to a specialist centre to have one.

You will be asked not to eat for six hours before the scan, although you may be able to drink. You will be given an injection of a mildly radioactive substance into a vein, usually in your arm. You may be asked to avoid talking and moving your head and neck area after the injection. The radiation dose used is very small. The scan is then taken after at least an hour. It usually takes 30-90 minutes.

You should be able to go home after the scan is over.

Other tests

Occasionally it is necessary to do other tests to give further information about the extent of your cancer. These may include a barium swallow or ultrasound scanning. Your doctor or nurse will explain these tests to you.

Waiting for your test results

It will probably take 7-10 days for the results of your tests to be ready, and this waiting period can be an anxious time. It may be helpful to talk to a relative or close friend.

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