Distant Metastasis

Distant metastasis in head and neck cancer—specifically head and neck squamous cell carcinoma (HNSCC)—is an ominous sign. While patients with certain cancer types who have distant metastases can live a long life (well-differentiated thyroid cancer, some adenoid cystic salivary gland carcinomas), many others will have complications related to the cancer. In general, the goal of managing distant metastasis is to try to prevent the tumour from growing and causing complications.

Certain tumour types are more likely than others to develop distant metastases. This includes adenoid cystic carcinoma, basaloid squamous cell carcinoma and neuroendocrine carcinomas (such as Merkel Cell carcinoma).

The exact incidence of distant metastases in head and neck cancer is difficult to determine. Historically, there was a long-standing belief that the lymph nodes in the neck were a barrier preventing cancer from spreading throughout the rest of the body. This was based on autopsy studies of patients who died with HNSCC; in over 4000 autopsies, the rate of distant metastasis was less than 1 percent. Whether the lymph nodes in the neck are a necessary step prior to cancer getting to distant sites is a matter of debate, and newer studies have shown that the rate of distant metastases can be as high as 25 to 50 percent in autopsy studies of patients with HNSCC.

According to a thorough analysis of information over many years, the following trends in stage at diagnosis of a few different types of head and neck cancers showed the following:

Site	Percentage of patients with distant metastasis at diagnosis 1974 to 1999
Oral cavity	6%
Lip	0.6%
Salivary gland	16%
Oropharynx	13%
Nasopharynx	10%
Hypopharynx	19%
Larynx	16%
Other mouth/pharynx	19%

Over the past few decades, doctors have made big advancements in eliminating the main tumour and spread to lymph nodes in the neck, which is called locoregional control. However, long-term survival has not changed significantly. One possible reason for this is while locoregional control has gotten better, the rate of distant spread of the cancer has not changed (or may have even increased as patients with locoregional control live longer). As it stands, while local and regional control of head and neck cancer is necessary to achieve a cure, it is not enough. There is something inherent tumours that makes them more likely to spread throughout the body.

Metastasis Diagnosis

Getting to a diagnosis begins with a history and physical examination. If the symptoms that make you or your doctor suspect cancer haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like with most cancers in the head and neck, this will include a combination of biopsy and imaging tests, the term that doctors use to refer to X-rays, MRIs, CT scans, etc.

If you came to a specialist after having a lesion removed and found it was cancer only after having the lesion removed, your doctor might skip some of the tests and jump to follow-up or additional treatment. Be sure to bring all the reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Doctors Visit

What to expect at your doctor visit?

Step 1: History

First, your head and neck specialist will take a thorough history of your health and address any specific concerns you may have.

Your doctor might ask questions such as:

How long has the problem been there?
Is it getting worse, better or staying the same?
Does it come and go?
Have you tried anything to make it better?
Is it painful?
Do you have numbness or tingling anywhere in your face or mouth?
Do you have any lumps or bumps in your neck?
Are you losing weight?
Do you have any other medical conditions?
Have you had any surgeries in the past?
What medications do you take? And do you have any allergies?
Have you ever been exposed to radiation in the head and neck?
What do you (or did you) do for a living?
Do you have a family history of cancer?

Step 2: Physical exam

Next, your doctor will examine you. Typically, if you’re seeing a specialist in head and neck disorders, you will get a thorough physical examination focused on the area of concern. Your doctor may see how wide you can open your mouth and then look and feel inside your mouth. The doctor is likely to feel around very thoroughly. If the tumour is in the mouth, then palpation of the tumour and the jaw will be very important. Knowing whether the tumour is fixed to the bone will be an important part of treatment and reconstructive recommendations.

You should also expect the doctor to:

Feel your neck thoroughly and carefully to check for any lumps or bumps.
Look inside your ears.
Look inside the front of your nose.
Check your cranial nerves by asking you to move your face, stick out your tongue, lift your shoulders, follow his or her fingers around with your eyes, do some simple hearing tests and test your sense of touch all over your face.

Your doctor might even put a camera in through your nose to take a look at the back of your throat and your vocal cords.

Step 3: Reviewing tests

After getting your history and performing a physical exam, your doctor will review any scans, laboratory work and pathology results you may have already had. Be sure to bring all of these with you to your appointment. Bring actual discs of any scans you’ve had, as well as any reports of those scans. If you are seeing a head and neck cancer specialist after a lesion was removed by a non-cancer specialist, you will need a thorough review of the pathology to discuss whether additional treatment is necessary. Try to obtain the actual glass slides that were prepared by the pathologist with the specimen taken during your biopsy procedure so your doctor can conduct a complete review. You might need more tissue removed or further treatment.

Step 4: Recommendations

Finally, your doctor will make recommendations about your next steps. This will likely include reviewing some of the studies you’ve already had done or ordering more tests. Once your doctor has all the necessary information, you should be given a preliminary stage and discuss treatment plans.

If the tumour is very large and is putting your breathing at risk, your doctor might recommend you undergo a tracheotomy, which is a breathing tube placed into the front part of your neck directly into your windpipe.

Also, if you are having difficulty getting enough nutrition by mouth because of a tumour, your doctor might recommend a feeding tube. This will help ensure you are able to undergo the treatment you will need to beat the cancer.