The role of the pathologist in head and neck cancer
This month, Professor Ruta Gupta sat down with RCPA President Dr Lawrie Bott to discuss the role of the pathologist in head and neck cancers for an episode of the Colleges podcast series, “The Pathologists Cut”. Prof Gupta holds many positions, including as senior staff specialist at Royal Prince Alfred Hospital, NSW Health Pathology and as lead pathologist with the Head and Neck Oncology and Thyroid Multidisciplinary team at Chris O’Brien Lifehouse Cancer Centre.
“Because of the area of the body that head and neck cancers affect, they can have very significant effects on the way a person eats or speaks, the way that they swallow or the way that they see and hear. Head and neck cancers are a very diverse range of cancers caused by a variety of reasons and risk factors, which are all grouped together because of their location on the body.
“Traditionally, the most frequent cause of head and neck cancer is smoking and drinking alcohol. However, in Australia, the rate of smoking is going down which means that we are seeing a decline in smoking associated head and neck cancers. Currently, we are seeing an increase in head and neck cancers caused by viruses such as human papillomavirus (HPV), which causes cancer of the oropharynx, or Epstein Barr Virus (EBV), which causes nasopharyngeal cancer.
“Head and neck cancers associated with smoking or alcohol are generally seen in older people and are much more common in men who have had a lifetime habit with alcohol or smoking. On the other hand, head and neck cancers caused by viruses tend to occur in much younger people. These patients tend to be in their early 40s to mid 50s and generally do not have lifetime exposure to tobacco. More recently, we are also seeing mouth cancers in young women, the reasons for which we don’t know currently,” said Prof Gupta.
HPV is a common virus that affects both males and females. There are more than 100 strains of HPV. Most types of HPV are harmless, do not cause any symptoms, and go away on their own. A small proportion of people, both men and women, will not clear HPV from their systems – these people are at higher risk of developing cancers, either of the head and neck, or in the case of women, cancer of the cervix.
“Because head and neck cancers that arise from HPV are generally hidden in the fold of the tonsils or right at the back of the throat, they can be very difficult to see. Surgeons will use an endoscope to look and take biopsies from the tonsils or the back of the tongue. These biopsies are then sent to the pathologist who will look under the microscope and make a cancer diagnosis. If cancer is present, there are certain tests we can do to see if it is related to HPV.
“Once a diagnosis of cancer is made, the patient then undergoes surgery. For head and neck cancer this is not just the removal of tissue with cancer. I.e., it is not just taking out the tongue, the jaw, or the tonsils, we also need to take out lymph glands from the patient’s neck. These are big surgical procedures and can require ICU care and long hospital admissions whilst the patient recovers. The diagnosis of head and neck cancer is a critical step to start the patient’s cancer journey.
“The pathologists examine the tissues removed during surgery to determine whether all of the cancer was removed or whether microscopic amounts is left behind or whether the cancer has invaded blood vessels and nerves. If this has happened additional treatment with radiotherapy or chemotherapy may be needed. Thus, it is the pathologist that informs every step of a patient’s cancer management,” said Prof Gupta.