Head and Neck Cancer Conditions, Diagnostics & Treatments

Computed tomography (CT or CAT) scans provide information about the status not only of soft tissue structures like organs, nerves and the brain, but also exquisite detail of even the smallest bony structures such as the vertebrae.

CT scans are considered to be one of the best ways to evaluate the sinuses. They are also helpful for evaluating swelling, inflammation and tumors.

During a CT scan, you will lie flat on a table that automatically slides into a doughnut-shaped piece of equipment. Most scans take only a few minutes and have a low risk of radiation exposure.

As X-rays pass through your body, different tissues absorb different amounts. Detectors inside the gantry measure the radiation leaving your body and convert the radiation into electrical signals. A computer gathers these signals and gives them a color ranging from black to white, depending on the signal's strength. The computer then puts the images together and displays them on a computer monitor. A technician in a separate room supervises your exam and watches the images on the computer. He or she can see and talk with you through an intercom.

Depending on what information is needed, the doctor may order a CT scan that is done using a contrast fluid or dye. This requires injecting a small amount of a colorless fluid (called dye or contrast) into a vein in your arm or hand before the CT scan. (If you have any allergies to drugs, iodine or other contrast agents, let your doctor know.)

A CT scan is painless. It can be done on an infant or toddler. Unlike magnetic resonance imaging (MRI), a CT scan can be done even if you have a pacemaker or cardioverter defibrillator.

Usually having a CT scan done takes less than an hour. Most of that time is spent preparing for the actual scan. As with an X-ray, a radiologist who is specially trained to read the images will look at the scan and send a report to your doctor or surgeon.

A CT scan is about as safe as an ordinary X-ray. There is some brief exposure to radiation. However, the information that a CT scan provides outweighs the risks of the radiation exposure.

Please talk to your doctor if:

• You are or think you might be pregnant. In this case, your doctor may want to recommend another type of diagnostic test.
• You have asthma or allergies. If it is necessary for you to have a contrast medium while the CT scan is done, there is a small possibility that you would have an allergic reaction to the medium.
• You have medical conditions such as diabetes, asthma, heart disease, kidney problems or a thyroid condition. These also may increase your risk of an allergic reaction to any contrast medium that may be needed during your CT scan.

A biopsy is the process of taking a sample of tissue to study under a microscope. A biopsy is always needed to confirm a diagnosis of cancer.

Because the head and neck areas have many delicate layers (often under bone and in vital areas involved in breathing, seeing or hearing or the brain, nerves and muscles), state-of-the-art imaging techniques may be required for a biopsy. This helps ensure that the tissue sample is taken from the proper place. It also protects healthy tissues and organs from damage in the process.

Tissue for a biospy can be removed from the body in several ways:

• Using a needle and syringe
• Using an endoscope. An endoscope is a thin, flexible tube that contains a fiber-optic light and a video camera at the end of the tube. Instruments can be inserted through the endoscope to the tissue to get samples for a biopsy.
• Surgery. The surgeon will make an incision through the skin to the area where a tumor is to collect tissue samples. The examination of the tissue sample is done before the operation so that the surgeon knows how to proceed.

Regardless of how the biopsy is collected, advanced imaging techniques may be used to guide the doctor.

Once the doctor has taken a tissue sample, it is studied by a specialist such as a pathologist or hematologist. (A pathologist is a specialist in examining body tissues for abnormalities; a hematologist is a specialist in examining blood and tissues such as bone marrow that form blood.) Sometimes both may be needed. These specialists seek to find out whether the tissue shows signs of cancer. If so, a pathologist or a hematologist will determine whether the cancer started at the site where the biopsy was taken or spread from some other part of the body.

A biopsy also helps a doctor determine how advanced the cancer is. The stages of cancer range from a scale of one to four. Stage 1 cancers are less advanced than Stage 4 cancers. How a cancer is placed on this scale depends on:

• The size of the tumor
• If (and how) it has spread through the body
• Where it has spread to. For example, has the cancer spread to other organs or the lymph nodes?
• How rapidly is the cancer growing

Knowing the stage of a cancer helps the doctor decide on the best treatment or combination of treatments for an individual patient.

A magnetic resonance imaging (MRI) scan can be critical to planning surgery, radiation therapy or treating head and neck disorders.

Although it is not as precise in evaluating bony structures, MRI gives superior detail of soft tissues like nerves, the spinal cord and the brain.

MRI is better than CT in assessing or describing soft tissue masses such as tumors.

MRIs can also be used to find and monitor injuries or disorders that affect the nerves including brain and spinal cord tumors and tissue abnormalities in persons with eye or inner ear diseases.

Before an MRI, it is important to remove any clothing, wigs, hearing aids, dentures or jewelry that may contain metal or electronics. If you have metal or electronic devices such as artificial joints or heart valves, a pacemaker or rods, plates or screws holding bones in place, be sure to tell the technician. Metal may interfere with the magnetic field used to create an MRI image and can cause a safety hazard. The magnetic field may damage electronic items.

Do not have an MRI scan if you have an implantable cardioverter defibrillator or pacemaker. The strong magnetic field created by the MRI unit may interfere with how these devices work. If you are or think you may be pregnant, be sure to tell the technician before having an MRI.

The MRI machine is a cylinder-shaped magnet in which you must lie totally still for short periods. You will lie down on a sliding table with your head in a brace. The table then slides into the unit. An MRI takes 15 minutes to an hour, depending on the part of the body being studied.

While MRIs are a relatively new technology, advances are continuing to be made. Some of these advances include:

• Spectroscopic MRIs, which measure certain metabolites in the body, helping doctors diagnose and treat conditions such as cancer or infections
• Diffusion MRIs, which create an image based on the microscopic movement of water in the spaces outside the cells; and
• Stronger magnets; that allow for more detail and faster imaging than conventional MRI machines.

The thyroid gland is located in the front of the neck at the level of the collarbone. It produces hormones that regulate the body's metabolism, bone growth, and heat production. Thyroid nodules are also called thyroid tumors.

More than 95% of thyroid nodules are benign (non-cancerous), but tests are needed to determine if a nodule is cancerous. Benign nodules include several types:

Multinodular goiter, is also called a nontoxic goiter. A goiter means the thyroid gland has grown too large. This usually happens when the pituitary gland (in the brain) creates too much thyroid stimulating hormone (TSH). If the goiter is small, the problem may be treated with thyroid hormone pills. Surgery is needed if the goiter is large or does not stop growing after taking thyroid hormones. A large thyroid gland can press against the trachea (windpipe) or esophagus (food tube) and cause difficult breathing or eating.

Chronic thyroiditis (Hashimoto's disease) is an inflammation of the thyroid gland that develops slowly. It frequently leads to a decreased function of the thyroid (hypothyroidism). Middle-aged women are most commonly affected. Thyroditis occurs when the body's own immune system destroys the cells in the thyroid gland. Chronic thyroiditis is most common in women and people with a family history of thyroid disease.

Thyroid cysts are nodules filled with fluid. They can be small or large and might appear suddenly. If a nodule has both fluid and solid parts, it is called a complex nodule. They need to be surgically removed if they cause neck pain or difficultly swallowing.

Benign follicular adenomas. The word follicular means the cells look like a group of small circles under a microscope. If the follicular cells are contained within the nodule, the condition is called benign. If the cells have invaded the surrounding tissue, the diagnosis is cancer. The nodule must be surgically removed and examined under a microscope to look for evidence of invasion into the normal thyroid tissue or blood vessels.

A biopsy is needed to determine if a nodule is benign or cancerous. Your doctor may just watch a benign nodule too see if it grows or causes symptoms. If it grows larger, you might need another biopsy. Thyroid hormones can suppress the activity of the gland so that it does not develop more nodules.

Thyroid Cancer

Every year 20,000 new cases of thyroid cancer are diagnosed in the United States. Women are three times more likely to have thyroid cancer than men. Thyroid cancer is most common after 30, but it can develop at any age.

There are four types of thyroid cancer tumors:

Papillary tumors account for 78% of thyroid cancers. They often spread to lymph glands in the neck (metastasis), but rarely spread to distant organs. The lungs and bones are the most common sites of metastasis.

Follicular (Hurthle cell) tumors are the second most common thyroid cancer. Metastasis to distant organs, (lungs, bones, brain, liver, bladder, skin) is common. Metastasis to the lymph glands is less common than in papillary tumors. Follicular tumors usually develop during 40-60 years of age. They occur three times more often in women than men. The cure rate is 97% or better if treated correctly.

Medullary tumors. Metastasis to the lymph nodes occurs in the early stage of the tumor. After surgery, the hormone calcitoin is measured every 4-6 months to check for recurrence of the disease. The survival rate is 90% if the disease has not spread outside of the thyroid gland. Survival is 70% if disease has spread to lymph glands in the neck, and 20% if the disease has spread to distant organs.

Anaplastic cancer is the least common type of thyroid cancer, but the most dangerous. Three years after diagnosis and treatment, only 10% of patients are alive. More than 90% of anaplastic cancers spread to the lymph glands in the neck and distant organs. The tumors grow rapidly. The average age of onset is 65 years of age and older.Men are two times more likely than women to have anaplastic cancer. Many patients require a tracheotomy (breathing tube placed into the neck) because the tumor presses against the trachea and inhibits breathing. This cancer must be detected early. The cure rate is very low.

Symptoms

Most thyroid nodules cause no symptoms, but sometimes the person or a family member might see or feel a lump in the front of the neck.

The lump may cause pain or difficulty swallowing. If the nodule is creating an excessive amount of thyroid hormone, the person might feel heat intolerance, palpitations, fast heart beat, nervousness, insomnia, increased bowel movements, absent periods, fatigue, weight loss, hair loss or muscle weakness.

Causes and Risk Factors

The exact reason nodules grow in the thyroid gland is not known. But these factors increase the risk:

• Heredity. If a parent or sibling had a thyroid nodule, the chance of developing a nodule is increased.
• Age. The risk of developing a nodules increases as you age.
• Gender. Woman develop nodule more often than men.
• Thyroiditis. Nodules are more likely to form in people who have chronic inflammation of the thyroid gland.
• Radiation exposure to the head or neck. In the 1940s and 1950s, many babies, children, and teenagers were treated with radiation for acne and enlarged tonsils. People who had these treatments have an increased risk.
• Exposure to nuclear power plant accidents, or radioactive particles released into the air during atomic weapons testing also increases the risk.

Diagnosis

A combination of symptoms, medical history, physical exams, and tests are used to determine a diagnosis. Thyroid nodules are often found during a routine physical examination. Your doctor might feel an abnormal lump on the front of your neck.

The TSH blood test measures a pituitary gland hormone that stimulates the thyroid gland. If the TSH level is increased, the thyroid gland may not be functioning properly. Additional blood tests are needed to measure other thyroid hormones. Both pituitary and thyroid tests are required to confirm that the problem is located in the thyroid gland.

T4 by RIA, T3 by RIA, and Thyroid Binding Globulin are blood tests used to measure the other thyroid hormones.
A thyroid scan measures the amount of iodine the thyroid can absorb.

Fine Needle Aspiration Biopsy. A needle is placed into the thyroid nodule; the cells are aspirated, and then examined under a microscope to determine if a nodule is cancerous.

Thyroid Ultrasound uses painless sound waves to create an image of the thyroid gland and identify nodules. Ultrasound can show if a nodule is solid or a fluid-filled cyst, but it cannot determine if a nodule is benign or malignant.

Thyroid Surgery and Treatments

Thyroid tumors require surgical removal of part or all of the thyroid gland (thyroidectomy). During a thyroidectomy, the surgeon might remove all of the thyroid gland or only the part that is diseased.

Radioactive Iodine treatments are given to most patients with thyroid cancer after the tumor is removed.

The laryngeal nerve (voice box nerve) is close to the site of surgery. After the operation, swelling of the nerve might cause weakness or paralysis of the vocal cords. But this is not common and rarely permanent.

Intraoperative Recurrent Laryngeal Nerve Monitoring is the latest technological tool used to prevent damage to the laryngeal nerve during surgery. Electrodes are placed near the muscles of the vocal cords and attached to a computer. The laryngeal nerve is monitored continually. If the nerve is inadvertently disturbed, the technician will alert the surgeon.

Total Thyroidectomy

• This operation is used for thyroid cancer and large non-cancerous tumors.
• After surgery, patients must take a thyroid hormone pill every day.

Low blood calcium levels (hypocalcemia) may occur when the entire thyroid gland is removed. This condition is usually temporary, but may require calcium supplements. Permanent hypocalcemia is rare.

Thyroid Lobectomy

One side (a lobe) of the thyroid gland is removed. This operation is used if only one nodule is found in the thyroid gland.

Thyroid Lobectomy with Isthmusectomy

The removal of a thyroid lobe and the part that connects the two lobes (the isthmus). More thyroid tissue is removed than in a lobectomy.

Radioactive Iodine

After surgery, radioactive iodine is used to eliminate any thyroid cells that might be hidden in the body or could not be removed during the operation.

A single radioactive iodine pill is taken four to six weeks after the thyroid operation. The remaining thyroid cells will absorb the radioactive iodine and be eliminated.

Thyroid cells are the only cells able to absorb iodine, so the iodine pill will not harm any other cells in the body. Radioactive iodine causes no hair loss and no nausea.

Throat cancers (oropharyngeal cancers) are becoming more and more common. These cancers often start in the tonsils or the base of the tongue. Before, these types of cancers called for intrusive surgeries. This may have involved splitting the jaw and rebuilding the tissue from other parts of the body.

TORS represents a new, less intrusive surgical method. This type of surgery goes through a patient's mouth and eliminates scarring and quickens recovery time.

TORS allows the area to function normally after surgery. The healing time is also shorter. More patients are being offered this choice of surgery at Cedars-Sinai.

During TORS, the cancer is reached by placing the needed tools down the throat with a high-definition camera and specialized instruments. The camera zooms in on the area of concern to give the doctor a magnified, three-dimensional view of the cancer.

The tools used to remove the cancer are controlled by the doctor outside of the body. This allows the tools to move in the same way the doctor is moving. The robot is fully under the control of the doctor. This allows them to operate in areas they could not otherwise reach.

Potential benefits of transoral robotic surgery for patients:

• Less blood loss
• Lowers the amount of chemoradiation or eliminates the need for it
• No need for tracheostomy
• Shorter hospital stay
• Quicker recovery to normal speech and swallowing
• No visible scarring or disfigurement

Staging usually occurs before cancer treatment is decided. The staging system helps the surgeon to decide the prognosis and to select the best treatment plan for each individual patient.

To stage a cancer, a pathologist examines the tumor cells under a microscope and describes the cells. A computed tomography (CT) scan , magnetic resonance imaging (MRI) or positron emission tomography (PET) scan helps determine if the tumor has spread to the lymph nodes or other organs. The pathology description, and the result of the scans, helps the doctor determine the stage.

The American Joint Committee for Cancer (AJCC) and the International Union Against Cancer (UICC) have agreed on a method to describe the stage of a cancer. This is called the TNM system:

T is for tumor
N is for node
M is for metastasis (has spread to other organs)
A number from 0-4 is assigned to each letter, such as T1 N1 M0. The number describes the size of the tumor: 0 is the smallest size and 4 is the largest.

Some N (node) categories have sub-categories that use the small case letters a, b, or c. Small case letters describe the extension of cancer:

a means cancer is in the lymph nodes
b means cancer is on one side only
c means cancer is on both sides
A sub-category tumor stage might be described as T2 N2a M0.

TNM is confusing. It is not necessary to know the exact meaning of each letter and number, but a basic knowledge is helpful. Your doctor will explain the stage of the tumor and the best treatment for you.