Faster Triage of Veterans With Head and Neck Cancer
If the patient is aged < 40 years and lymph nodes have been present for less than 2 to 4 weeks, are tender, or are associated with fever or poor dental hygiene, then an infection may instead be the cause. Dentistry referral and/or an antibiotic trial should be considered. Lymphomas, also common in the neck, may be accompanied by “B symptoms” (fever, night sweats, unintentional weight loss of > 10%).24 If lymphoma is suspected, fine-needle aspiration (FNA) for cytology and flow cytometry should be performed. If lymphoma is confirmed, the GP should refer the patient to an appropriate medical oncologist for further evaluation, which may include referral to Oto-HNS for core or open biopsy. Contraindications to FNA of a neck mass include paragangliomas, such as a carotid body tumor.
Other cancers of the upper aerodigestive tract also often spread to the neck nodes and may initially present as a neck mass. A thorough examination can usually point to the primary cancer, and FNA will provide the diagnosis with high specificity and sensitivity.25 Midline cystic neck masses in close proximity to the hyoid bone are likely thyroglossal duct cysts. If these cysts grow, they likely require removal.
Salivary glands. The submandibular, sublingual, and parotid are the major salivary glands. There also are hundreds of small salivary glands scattered through the oral and pharyngeal mucosa. Tumors arising from the salivary glands represent about 6% of all head and neck masses; these tumors are nearly 3 times more common in men than in women.26 About 80% of salivary gland tumors originate in the parotid gland; patients with such tumors typically present with a painless parotid mass.26 In advanced cases, patients may present with skin infiltration and facial paralysis secondary to involvement of
the facial nerve that courses through the parotid gland after it exits the temporal bone near the mastoid tip.
Salivary gland tumors are most commonly benign, and pleomorphic adenomas are the most common benign parotid neoplasm.27 The incidence of malignancy is highest in submandibular, sublingual, and minor salivary glands. There are numerous primary salivary gland malignancies, such as mucoepidermoid carcinoma, adenocarcinoma, and adenoid cystic carcinoma. Facial skin SCC may metastasize to periparotid nodes. There are also multiple nonneoplastic causes of salivary gland inflammation. Recurrent diffuse, painful gland enlargement may be suggestive of recurrent sialadenitis and may be
secondary to a stone or xerostomia associated with dehydration or use of diuretics, antidepressants, or lithium. Multiple lymphoepithelial cysts may be associated with HIV and do not require resection.28
Management
After taking a thorough history and performing a physical examination, the physician evaluating a patient for HNC should proceed with diagnostic testing followed by referral to a specialist.
Diagnostic Testing
Laboratory values. Although laboratory values are unlikely to help in evaluation of a malignancy, elevated white blood cell count, erythrocyte sedimentation
rate, and C-reactive protein level are markers of a general inflammatory process that may support a clinically suspected diagnosis of infection. Values that decrease over time may represent progress toward disease resolution.29
Imaging. If malignancy is suspected, imaging should be obtained. Imaging has an important role in corroborating examination findings of a mass. Imaging
also provides an accurate baseline assessment of tumor size and extent. Recommended imaging modalities include:
- Ultrasonography (US). This quick and inexpensive modality can be used to visualize suspicious neck lesions. It is helpful in performing real-time assessments and differentiating cysts from solid masses and abscesses from reactive lymph nodes or infiltrative tumors. Challenges with US include its inability to penetrate bone and practitioners’ variable interpretation of images. A different modality invariably is needed to document location and spread of suspected HNC.
- MRI and CT. These are necessary for HNC evaluation and staging. Generally, they are equivalent in node assessment, but MRI is preferable in tongue and pharynx evaluation, and CT is preferable in the larynx. An ideal image should extend from the skull base to the clavicles, demonstrating the extent of the primary tumor and potential metastases to the neck nodes. As MRI is best protocoled by an experienced head and neck radiologist, it is preferable to refer the patient to such a specialist and allow Oto-HNS to arrange the imaging. Contraindications to MRI include pacemakers and shrapnel (common among veteran patients) and claustrophobia (common among patients with PTSD).
- PET-CT. This modality helps in staging, detecting distant metastases, assessing treatment response after chemoradiation, and locating the primary cancer when a proven neck metastasis has no obvious source. Whether PET-CT should be performed before initial referral should be discussed with the specialist. A case with a proven distant metastasis likely is not operable and would be better served with a referral to medical oncology.
Biopsy. For almost all HNCs, the initial biopsy modality should be FNA. Although intraoral lesions may benefit from incisional biopsy, this procedure should not delay triage and may be outside the scope of practice for many GPs. A GP can arrange for FNA to be performed before the referral appointment. This modality has excellent diagnostic sensitivity and specificity.30,31 In the setting of equivocal or negative results despite a high index of suspicion, having a more experienced cytopathologist repeat the FNA is often warranted. Excisional biopsy may be warranted if FNA is nondiagnostic or lymphoma is diagnosed.
Other Interventions
In some cases, the GP has additional important roles— in preparing the patient for the possibility of surgery, treating related conditions, helping the patient cope with this new medical challenge, improving nutrition, and promoting cessation of alcohol drinking and tobacco smoking.
Surgery. For patients with biopsy-proven HNC, preoperative assessment by the GP helps provide clearance for surgery, reduces time to treatment, and lessens the likelihood of postoperative complications. A recent study found that VA patients aged ≥ 70 years had a 30-day postoperative mortality rate of 6% and at least a ≥ 20% risk for a major complication during their hospital stay.32 Given these risks and the overall higher rate of chronic diseases among veterans, the authors recommend preoperative evaluation of comorbidities with particular emphasis on cardiac, renal, and pulmonary status. In addition, specific examinations (eg, electrocardiogram, chest radiograph, basic laboratory tests, liver profile test) are recommended for patients with a history of alcohol abuse.
Malnutrition. At initial diagnosis, many patients with HNC have significant weight loss.33 Unfortunately, the required complex treatment modalities increase malnutrition rates and decrease quality of life.34 Preventive strategies are, therefore, key in improving patients’ overall health. The authors recommend that GPs consider early nutritional consultations and as-needed speech therapy evaluations to provide preventive strategies and exercises to maintain proper swallowing function.35 Patients who are unable to eat because of aspiration caused by a large tumor should be admitted for preoperative gastric tube placement to improve nutrition and, ultimately, surgical outcome. A large percentage of veterans with HNC also have depression, which may lead to decreased appetite.36 Mental health consultations can help in these circumstances, as can use of mirtazapine, which increases appetite and treats depression-related symptoms.
Pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be recommended for relief of uncontrolled mild to moderate pain, but they must be discontinued 1 week before surgery to reduce the risk for bleeding complications. The NSAIDs should be avoided entirely in patients with untreated friable tumors of the aerodigestive tract. In patients with biopsy-proven cancer, pain control can involve opiates per World Health Organization guidelines.37 Patients with head and neck SCC often have neuropathic pain, which is more effectively treated with gabapentin.
Alcohol drinking and tobacco smoking. Promoting cessation of these habits is essential for all patients, including those already diagnosed with cancer. Encouraging cessation as well as overall healthy lifestyle choices can reduce cancer risk and improve overall health—and may be the single most efficacious intervention a physician can offer.
Referral
Most patients with suspected HNC should be referred to Oto-HNS. In cases in which lymphoma is most highly suspected, medical oncology is the most appropriate initial referral. Early dental consultation is also necessary if an obturator will be needed (eg, as with a hard palate malignancy) or if irradiation is planned (radiation-induced xerostomia significantly increases the risk for dental caries).38 For all new cancer diagnoses, the GP can contact the Oto-HNS specialist for help in tailoring the patient evaluation to the practices and resources at the GP’s home institution and reduce time to treatment.
Conclusion
General practitioners are essential in identifying and triaging veterans with HNC. High-risk patients with a growing mass require proper assessment, including a thorough history and physical examination, FNA for diagnosis, and appropriate specialist referral. Although this article provides a helpful framework for thinking about patients with HNC, the authors encourage GPs to check the National Comprehensive Cancer Network guidelines for additional information on the topics covered here. With this knowledge, GPs can improve outcomes for veterans with HNC.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
