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.