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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 91-95

Pattern of Head-and-Neck Malignancies in the Pediatric Population


1 Department of ENT, PT JNM Medical College, Raipur, Chhattisgarh, India
2 Department of Anesthesia, PT JNM Medical College, Raipur, Chhattisgarh, India
3 Department of Pediatrics, AIIMS, Raipur, Chhattisgarh, India

Date of Submission10-May-2020
Date of Decision23-May-2020
Date of Acceptance21-Jul-2020
Date of Web Publication8-Dec-2020

Correspondence Address:
Harbansh Singh
Department of ENT, Pt JNM, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhnps.jhnps_21_20

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  Abstract 


Background: Head-and-neck malignancies are uncommon in childhood unlike in adults, also it contributes to low proportion of overall cancer incidence among children. The number in India has been increasing in the recent past. Hence, we conducted a study to know the pattern of head-and-neck cancers in hospitalized patients of 0–18 years’ age group. Aim: The aim was to study the pattern of different types of head-and-neck malignancies in the pediatric age group (<18 years) in a referral hospital. Subject and Methods: We have conducted an observational study of pediatric head-and-neck malignancies in our tertiary care center. All children in the age group of 0–18 years were included in the study. A total of 72 cases were taken retrospectively and prospectively from various departments of hospital which deal with pediatric patients. Results: Our study comprises total 72 cases, maximum cases were of acute lymphocytic leukemia with secondaries in neck n = 21, followed by 9 cases were of acute myeloid leukemia with secondaries in the neck. Carcinomas of the nasopharynx and parotid both were 8 in number; 15 cases were of Hodgkin/non-Hodgkin lymphoma with involvement of neck nodes. The least number of cases was of carcinoma mandible, Burkitt lymphoma, and chronic myeloid leukemia with secondary neck nodes. Most cases presented with right-sided neck mass or lymphadenopathy. Male-to-female ratio was 1.78:1 in all cases. Most of the cases were diagnosed either by bone marrow aspiration biopsy, fine-needle aspiration cytology, or excisional biopsy. Conclusion: Malignancy is one of the differentials of pediatric neck masses. Hematological malignancies and lymphomas are still two major contributors of head-and-neck cancers in the pediatric age group.

Keywords: Head and neck malignancy, lymphoma, neck masses, pediatric


How to cite this article:
Mungutwar V, Thakur M, Singh H, Singh S, Hota D. Pattern of Head-and-Neck Malignancies in the Pediatric Population. J Head Neck Physicians Surg 2020;8:91-5

How to cite this URL:
Mungutwar V, Thakur M, Singh H, Singh S, Hota D. Pattern of Head-and-Neck Malignancies in the Pediatric Population. J Head Neck Physicians Surg [serial online] 2020 [cited 2021 Jan 23];8:91-5. Available from: https://www.jhnps.org/text.asp?2020/8/2/91/302622




  Introduction Top


Head-and-neck malignancy is an important cause of mortality in the pediatric population. The incidence of death by cancer in children of the age group of 5–14 years is second only to road traffic accidents. The incidence rate of childhood cancer across the world varies between 50 and 200/million children.[1] Approximately 84% of childhood (0–14 years) cancers occur in the low- and middle-income countries. Despite improvements in managing many childhood malignancies, the incidence of childhood malignancy continues to rise. Although head-and-neck masses are commonly seen in children, malignancy is unlikely in most of the cases. An increase in the incidence of head-and-neck cancer among children younger than 15 years has outpaced the overall rise in malignancies for this age group in the recent past.[2] Most common pediatric head-and-neck malignancies include non-Hodgkin’s lymphoma (NHL), Hodgkin’s lymphoma (HL), rhabdomyosarcoma, thyroid malignancies, nasopharyngeal carcinoma, salivary gland malignancies, and neuroblastomas.[3] Other rarer head-and-neck malignancies are nonrhabdomyosarcoma, soft-tissue sarcomas, malignant teratomas, primitive neuroectodermal tumors, and skin cancers.[4] The differential diagnosis of head-and-neck masses includes congenital, inflammatory, and neoplastic lesions. Most cases of head-and-neck masses are inflammatory in nature during childhood. Persistently enlarged lymph nodes raise more concern, especially when enlarged lymph nodes are present within the posterior triangle or supraclavicular space of the neck. Nodes that are painless, firm, and nonmobile or single dominant node that persists for more than 6 weeks all raise concern for malignancy.[5] Neoplasm of the head-and-neck region accounts for approximately 5%–10% of all childhood malignancies.[2],[6],[7] The risk factor for childhood malignancies is still unexplored. A few environmental factors such as exposure to radiation have been linked with some types of childhood cancers. This study is an effort to explore the recent trends and epidemiology of childhood cancers of the head-and-neck region in our area. We found that secondaries of blood-borne cancers, i.e., leukemias, were still most common head-and-neck cancer among the childhood age group. Carcinomas of the nasopharynx and maxillary and oral cancers are also predominant in children, followed by lymphomas. The result of this study will serve as a reference source for clinicians, epidemiologists, researchers, and health administrators.


  Subjects and Methods Top


This study was conducted to find the pattern, associated risk factors, and current epidemiology of different types of head-and-neck malignancies in the pediatric population. It was an observational study conducted for a 3-year period from April 2016 to April 2019 in the age group of 0–18 years in a tertiary care referral center in central India. Institutional ethical committee approval has been obtained before starting of the study. Patients were selected from the routine outpatient departments of ENT, oncosurgery, pediatric surgery, and pediatrics. Patients of the age group of 0–18 years with diagnosed head-and-neck malignancies were enrolled as case and patients with intracranial tumor, ophthalmic malignancies, and leukemias without lymphadenopathy were excluded from the study. Complete head-and-neck examination including neck nodes, any growth in the oral cavity, nasal cavity, and neck area was thoroughly done. Investigations such as Ultrasonography (USG), fine-needle aspiration cytology (FNAC), biopsy, bone marrow aspiration, and immunohistochemical were advised accordingly. Radiological investigations were performed to know the extension of malignancies. The cases were selected by random sampling. The sample size was calculated using the formula n = (1.96) 2pq/d2. A total of 72 cases were included in the study, of which 49 were retrospective and 23 prospective. Patients with intracranial tumors, ophthalmic malignancies, and leukemia without lymphadenopathy were excluded from the study.


  Results Top


According to our study of total of 72 cases, maximum cases were of acute lymphocytic leukemia (ALL) with secondaries in the neck, i.e., 21 (29.72%), followed by 9 cases (16%) of AML with secondaries in the neck. Carcinomas of the nasopharynx and parotid were both 8 in number (10.81% each). A total of 15 cases (19%) were of HL/NHL with the involvement of neck nodes. The least number of cases was of carcinomas of the mandible, Burkitt lymphoma, chronic myeloid leukemia (CML) with secondaries in the neck, and carcinoma of the mandible [Table 1]. Overall frequency distribution of cases with the highest occurrence according to their symptoms was found to be right / left neck swelling in 48 cases (64.8%) followed by right / left nasal mass in 12 cases (16.2%) and oral swelling /mass in 8 cases (11%). Symptoms of parotid swelling and proptosis right/left were found to be equal, i.e., 6 (8.1%). Associated symptoms such as fever, pain, and halitosis were found in 31 (41.8%) cases.
Table 1: Cases according to the diagnosis (n=72)

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The overall age group and sex-related frequency distribution of children included in the study showed male predominance, i.e., 65.2% (n = 46). Maximum cases were in the age group of 13–18 years [Table 2].
Table 2: Age and sex wise incidence (n=72)

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For the diagnosis of neck masses, computed tomography scan was found to be the most common radiological investigation. Leukemia with secondaries in the neck was found in maximum number of cases. Confirmation was done mostly by bone marrow aspiration biopsy. FNAC and by gland biopsy were other two commonly used techniques for diagnosis.

According to their site-wise distribution, leukemia with secondaries (AML, ALL, and CML) constituted 44% of cases (n = 31) and it was found maximum as right neck mass in 15 cases (48%), followed by bilateral neck mass in 9 cases (29%) and left neck in 7 cases (22.5%). The second most common was carcinoma of the nasopharynx/maxillary and oral cancers, i.e., 16 (22.5%), in which right side neck involvement was seen in 7 cases and 2 cases has left side involvement. The rest cases were presented with or without involvement of neck nodes. Thirteen cases of lymphoma (HL/NHL) involved the right side of neck nodes, seven cases have left side involvement, and bilateral and no neck node involvement was seen in only two cases.

Sex-wise distribution is mentioned in [Table 3] which shows a higher incidence of leukemias (ALL/AML/CML), HL/NHL, and carcinoma of the nasopharynx/maxilla/oral cavity in males than females.{Table }

Overall frequency distribution of cases according to presenting symptoms, highest incidence of neck swelling right/left seen in 48 cases (64.8%) followed by nasal mass right/left i.e., 12 (16.2%) and oral swelling/mass in 7 cases (10.8%) symptoms of parotid swelling and proptosis right/left was found equal i. e., 6 (8.1%). Associated symptoms such as fever, pain, and halitosis were found in 31 (41.8%) cases [Table 4].
Table 4: Symptom-wise presentation

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The risk factor for leukemia, lymphoma, carcinoma parotid, and thyroid carcinoma was either poor nutrition or excessive solar exposure, but in case of nasopharyngeal, oral, or maxillary cancer, the most important risk factor was tobacco chewing followed by poor nutrition. Tobacco chewing with betel nut is very common in the central part of India that contributes to a higher incidence of oral cancers among the adolescent age group.


  Discussion Top


Head-and-neck masses are some of the common entities encountered in children and they may be diagnosed as congenital, inflammatory, or neoplastic. Most of these lesions are benign in nature, and the overall incidence of head-and-neck tumors in pediatric age group is very rare, but some studies show incidence up to 12% of all neck masses.[2],[8],[9] Malignancies in pediatric population are increasing, especially hematological are rising in the past decade among Indian children.[10] In our study of the total of 72 cases, we found that maximum cases of head-and-neck malignant neck masses in the childhood group are secondaries of leukemia and lymphoma. The overall incidence of head-and-neck malignancy in children is approximately 10% in most of the studies, the most common being lymphoma.[2] Our study also supports the evidence.

Sengupta et al. found in their study lymphoma was commonest (43.39%), followed by rhabdomyosarcoma (20.5%) and nasopharyngeal carcinoma (15.09%) presented as neck mass (lymphadenopathy) in the pediatric population. The malignant lesions are predominantly seen in the age group of 10–12 years (47.17%), and overall male to female sex ratio was 1.78:1, except in thyroid carcinoma and neuroblastoma where the ratio was similar in both sex.[6] This distribution was similar to our study as we found that most cases were from the age group of 13–18 years and the sex ratio was 1.76:1 for male-to-female cases.

A study of pediatric head-and-neck masses (n = 98) by Unsal et al. showed that most cases were of infectious origin, congenital and neoplastic masses were 27.6% and 23%, respectively. HL was the most common (39.1%) among all malignancies presented as a neck mass. Sixty-seven percent of all neck masses were solid, and the lateral levels of the neck (mostly right side) were the most affected locations (44.9%).[11]

Ayugi et al. (2011) studied the Kenyan population of the pediatric age group and they found 59 malignant cases from a total of 235 cases of an acquired neck mass. In all malignant cases, 42% cases were either NHL or HL, representing the maximum number of malignant cases. Second, they also found that ALL was approximately 24% with neck masses. Nasopharyngeal carcinoma was also in significant numbers.[12] In our study, we also found a similar pattern of incidence of head–and-neck masses.

In a large Turkish study by Balikci et al., of 630 cases of neck masses, they found that 147 cases were malignant neoplastic and most of them were diagnosed with lymphoma (n = 60), followed by squamous cell carcinoma (n = 42), undifferentiated carcinoma (n = 15), mucoepidermoid carcinoma (n = 7), adenocarcinoma or papillary carcinoma (n = 6), or acinic cell carcinoma (n = 5). In this study, they have not included the secondary neck masses following childhood leukemia. Our results are similar to this study if we have not considered secondary masses of leukemias.[13]

In a study of fine-needle aspiration biopsy-based 233 diagnosed cases of childhood head-and-neck mass lesions conducted by Eşki et al., 24 (10.3%) were malignant. The most common malignancy was HL (approx. 33%) which is very similar to our study.[14]

In our study, we found that in maximum cases, risk factor was poor nutrition and excessive solar exposure 17 (40.4%), followed by betel nut chewing in 3 cases (7.15%) and least common was tobacco chewing only in 1 case (2.4%). As maximum cases were from poor socioeconomic status and they work in outdoors and farms, so they have relatively excess solar exposure as well as they have higher incidence of malnutrition.

As per the management of cases, 53 (73.6%) patients received chemotherapy which was maximum and the least modality used was isolated radiotherapy in only 2 (2.7%) cases. Surgical intervention required in 6 (8.3%) cases, while combined therapy was given in 11 (15.2%) cases.

The limitation of this study is that diagnosis and classification was not done by one physician or surgeon. Data were collected from various departments with interdepartmental variability in approach for pediatric neck masses. It was a hospital-based study which cannot be a reflection from population so a community-based study would have been a better option to know the actual burden of head-and-neck malignancy in children. Another negative point is that we included the cases from a wide age group, i.e., 0–18 years. There is a wide heterogeneity of diagnosis, incidence, and presentation in this age group of population.


  Conclusion Top


The incidence of head-and-neck malignancies among the pediatric age group is very rare. However, it is increasing at a greater rate compared to other childhood cancer. In most cases, detailed history and physical examination are the mainstays for diagnosis, but histological and radiological investigations are necessary for differentiation. Malignancy should be an important differential diagnosis for all head-and-neck masses. Hematological malignancies are still more common than others in the pediatric population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.



 
  References Top

1.
Asthana S, Labani S, Mehrana S, Bakhshi S. Incidence of childhood leukemia and lymphoma in India. Pediatr Hematol Oncol J 2018;3:115-20.  Back to cited text no. 1
    
2.
Albright JT, Topham AK, Reilly JS. Pediatric head and neck malignancies: US incidence and trends over 2 decades. Arch Otolaryngol Head Neck Surg 2002;128:655-9.  Back to cited text no. 2
    
3.
Satyanarayana L, Asthana S, Labani SP. Childhood cancer incidence in India: A review of population-based cancer registries. Indian Pediatr 2014;51:218-20.  Back to cited text no. 3
    
4.
Chadha NK, Forte V. Pediatric head and neck malignancies. Curr Opin Otolaryngol Head Neck Surg 2009;17:471-6.  Back to cited text no. 4
    
5.
Tracy TF Jr., Muratore CS. Management of common head and neck masses. Semin Pediatr Surg 2007;16:3-13.  Back to cited text no. 5
    
6.
Sengupta S, Pal R, Saha S, Bera SP, Pal I, Tuli IP. Spectrum of head and neck cancer in children. J Indian Assoc Pediatr Surg 2009;14:200-3.  Back to cited text no. 6
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Dickson PV, Davidoff AM. Malignant neoplasms of the head and neck. Semin Pediatr Surg 2006;15:92-8.  Back to cited text no. 7
    
8.
Al-Mayoof AF. Neck masses in paediatric population: An experience with children attended the central teaching hospital of pediatrics in Baghdad 2008-2009. Afr J Paediatr Surg 2015;12:136-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Arboleda LPA, de Mendonça RMH, Lopez EEM, Araújo ALD, Palmier NR, de Pauli Paglioni M, et al. Global frequency and distribution of head and neck cancer in pediatrics, a systematic review. Crit Rev Oncol Hematol 2020;148:102892.  Back to cited text no. 9
    
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Das S, Paul DK, Anshu K, Bhakta S. Childhood cancer incidence in India betweem 2012 and 2014: Report of a population-based cancer registry. Indian Pediatr 2017;54:1033-6.  Back to cited text no. 10
    
11.
Unsal O, Soytas P, Hascicek SO, Coskun BU. Clinical approach to pediatric neck masses: Retrospective analysis of 98 cases. North Clin Istanb 2017;4:225-32.  Back to cited text no. 11
    
12.
Ayugi J, Ogengo J, Macharia I, Olabu B. Pattern of acquired neck masses in a Kenyan paediatric population. Int J Oral Maxillofac Surg 2011;40:384-7.  Back to cited text no. 12
    
13.
Balikci HH, Gurdal MM, Ozkul MH, Karakas M, Uvacin O, Kara N, et al. Neck masses: Diagnostic analysis of 630 cases in Turkish population. Eur Arch Otorhinolaryngol 2013;270:2953-8.  Back to cited text no. 13
    
14.
Eşki E, Akdoğan V, Türkoğlu SB, Sökmen MF, Çaylaklı F, Özer C, et al. Pediatric mass lesions of the head and neck region and fine-needle aspiration biopsy results. Turk Arch Otorhinolaryngol 2016;54:29-34.  Back to cited text no. 14
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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