In Italy, about 25,000 new cases of head and neck cancer are found (including thyroid) annually. According to an AIRTUM 2013 (Italian Association of Cancer Registries) report, in Italy these tumours are ranked fifth by frequency. Most cases (over 90%) are squamous cell carcinomas that develop from epithelial cells that line the mucous membranes in the area. There are less common tumours that may originate from other tissues, such as adenocarcinomas from the salivary glands and thyroid, melanomas from the cells producing melanin, lymphomas from lymphoid tissues and so on.

Cancers of the oral cavity

Oral cavity cancers include a set of malignancies, mainly carcinomas that originate from the mucous membranes (95%), but also tumours of salivary origin, connective tissue or melanomas (5%) that originate at the level of the lip, tongue, floor of the mouth, cheeks, gums, palate (hard and soft) and the anterior tonsil pillars (mouth opening). In Italy, the incidence is 4 cases per 100,000 inhabitants, with an average age of 50 but in 15% of cases they are young patients. Men are affected about two times more than women. 

Laryngeal cancers

The larynx, the organ of the voice and other functions, is located in the upper part of the trachea and is surrounded by the hypopharynx (the lower part of the throat, where food passes). The larynx has three main functions: creating the voice by vibration of the vocal cords, preventing the entry of food into the lungs when swallowing via the sphincter and allowing air to pass into the lungs when breathing.

Cancers of the larynx are mainly found in the vocal cords, but may also be found in the structures close to the vocal cords. In Italy, laryngeal cancer is the most frequent among the head and neck tumours. It is estimated that about 5,000 new cases are diagnosed each year. In most cases, the tumours develop in men.

Tumors of the nasopharynx

The nasopharynx is located behind the nose and is part of the upper portion of the pharynx. It connects the two nasal cavities with the oropharynx and with the ears, through the two Eustachian tubes during swallowing. 

Cancer of the nasopharynx most frequently originates from the dimples that lie above the Eustachian tube (Rosenmuller’s dimples) and from the nasopharynx. It may be extended to nasopharyngeal and nasal passages, the sinuses, the soft palate up to the ethmoid, the anterior, and sometimes the medial cranial bones. It is an endemic cancer in Southeast China (30-80 cases out 100,000/year) but it is also present in the rest of Asia, the Mediterranean area, Africa and the United States.

Tumors of the oropharynx

The oropharynx is the region situated to the rear of the mouth. It includes the tonsil region, the base of the tongue, the posterior wall of the pharyngeal axis, and the soft palate (uvula).  

The most common symptoms are pain on swallowing that does not regress with the use of common symptomatic drugs, a sense of hindrance in swallowing and the presence of an ulcerated and/or bleeding lesion. In some cases, the first symptom may be represented by the appearance of a swollen lymph node in the neck, that is not usually painful and which may occur suddenly and does not regress after systemic therapy (anti-inflammatory and antibiotics).

Tumors of the hypopharynx

The hypopharynx is continued inferiorly with the cervical oesophagus and is situated post-laterally to the larynx with which it has a close relationship, enfolding almost 180° of it. Internally it is made up of mucosa, it does not have any cartilage or bone scaffold but only a muscular layer that forms the outer structure. Ninety-five percent of cancer cases in this district develop from the cells of the mucosal surface in the form of squamous cell carcinomas. 

Tumors of the thyroid

The thyroid is an endocrine gland located at the base in the middle of the neck, just in front of the trachea. Tumours in this area may be benign or malignant. The histology of the tumour varies depending on the cell of origin. Papillary and follicular carcinomas are well differentiated, and arise from the thyroid follicle; medullary carcinomas arise from the supporting C-cells. Poorly-differentiated carcinomas and anaplastic carcinomas are very aggressive variants. To date, malignant disease of the thyroid is the cancerous disease with the greatest increase in incidence in the population, regardless of sex and age. In women, it stands at second place after breast cancer in the age range between 0 and 50, and at the fifth place overall after breast, colon, lung, uterus in a patients over 50 years. In Italy, the incidence is 16,000 new cases in 2013. 

Tumors of the parotid gland

The salivary glands are found in and around the mouth and are divided into major and minor. The former are bilateral and symmetrical, including the parotid gland (in front of the ear and behind the angle of the mandible), the submandibular gland (posterior inferior mandible) and the sublingual gland (under the floor of the mouth to the sides of the tongue). The latter are present in different regions of the face, including the nose and sinuses, and are very numerous (hundreds) but too small to be seen with the naked eye. 

The salivary gland tumours are rare and account for no more than 1% of all cancers. They can occur at any age but are unlikely to occur before the age of 40. Men and women are both affected with no substantial differences between the two. About 70% of cancers arise from the parotid, 10-20% from the submandibular glands while the sublingual glands are rarely affected. The histology of these tumours depends on the type of originating cell. Examples are muco-epidermoid carcinoma (more common in the parotid), cystic adenoid carcinoma, and many different types of adenocarcinoma (clear cell, basal cell, not specified, mucinous). In the salivary glands other cancers such as squamous cell carcinomas, undifferentiated carcinomas, melanomas and lymphomas (very rare) may be generated.

Cancers of the face skin

Seventy-five percent of skin cancers affect the head and neck district. In most cases they are basal cell cancers, squamous cell carcinomas and melanomas diagnosed and treated in the initial stages by dermatologists. 

Good standards for prevention

• Adopting a healthy lifestyle, not smoking and limiting alcohol abuse.
• Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkin, apricots, herbs (probable evidence).
• Keeping a careful eye on oral hygiene.
• Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
• After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
• Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck district.

The most common symptoms are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.

Cancers of the oral cavity

As in other head and neck cancers, risk factors are related to lifestyle habits, especially the abuse of tobacco and alcohol. Also a poor diet and poorly-conditioned teeth seem to act as co-factors. The role of viruses (HPV Papillomavirus) is currently under investigation. Cancers of the oral cavity are manifested primarily by a lesion of the mucous membrane. This initially superficial lesion appears like a milky white or red spot as well as a small ulceration that does not usually spontaneously heal, and sometimes bleeds on rubbing. 

The most important characteristic differentiating this lesion from other inflammatory and traumatic lesions (for example ulcer or biting injury) is that it is completely asymptomatic, at least initially. In more advanced stages it may appear as an ulceration, submucosal nodule, more or less hard, florid, cauliflower-like vegetating lesion. In some cases, a pain may occur that radiates to the ear, with difficulty swallowing, bad smell of the mouth, whereas in others, there may be a swelling of the neck.

Diagnosis is easy, given the accessibility of the mouth. Histological diagnosis can be made by a simple biopsy under local anaesthesia, a procedure with minimal pain that can be performed in few minutes. An early diagnosis of vocal cord cancers can be done using a fibro-laryngeal endoscopy with NBI and iSCAN. These very sophisticated instruments allowing us to diagnose lesions at the onset stage or when they are very small and hardly recognisable with traditional standard methods.

Ultrasound, magnetic resonance and PET (or even a total body CT) allow correct staging. There are no blood tests that can detect the presence of a cancer of the oral cavity.

Cancers of the larynx

The most important risk factors are tobacco and alcohol, especially the combination of the two. Other possible risk factors include prolonged exposure to wood and metal dusts, asbestos, paint fumes and other chemical solvents. Other factors that seem to play a non-marginal role in the development of laryngeal cancer are a diet low in vitamins A and E, gastro-oesophageal reflux disease that chronically expose throat to acidic gastric juices from the stomach, and infection by human papillomavirus (HPV). 

The most common symptoms include dysphonia (change or lowering of the voice that does not improve within 2-3 weeks), and difficulty or persistent discomfort when swallowing. In addition another alarm bell may be the presence of a swelling in the neck (because of a diseased lymph node).

Diagnosis can be made through a clinical and instrumental evaluation (fibre-optic video) in the clinic. If diagnosed early (early stage) it is possible to propose a minimally-invasive laser microsurgery of the mouth in a single operative session, even in day surgery. For tumours at a more advanced stage, diagnosis using biopsy under general anaesthesia is mandatory, in order to define the best treatment proposal.

Ultrasonography, computed tomography (CT), magnetic resonance in selected cases, and PET (or a total body CT) allow proper staging for appropriate care.

Tumors of the nasopharynx

These tumours are less frequently associated with known risk factors for head and neck cancers such as tobacco or alcohol. They are recognised as having a multifactorial aetiology, genetic, viral (presence of the Epstein Barr genome or EBV in the DNA of the tumour cells of patients), food (consumption of salted fish, or smoked meat). In the early stages there is no sign; in the later stages there may be signs and symptoms such as continuous nasal obstruction, frequent episodes of nasal bleeding, feeling of muffled ears (due to obstruction of the Eustachian tube), swelling in the neck due to the spread of the disease to the lymph nodes. Onset of constant and lateralised headache, or visual disturbances such as double vision are indirect signs of the involvement of the skull base. 

Diagnosis is made by clinical and fibre-optic video examinations of the nasal cavity combined with an outpatient biopsy. For staging completion an ultrasound of the neck with possible fine-needle aspiration, magnetic resonance with contrast material, FDG-PET (or CT thorax and abdomen and bone scintigraphy) and quantitative evaluation of EBV DNA may be required before starting treatment.

Tumors of the oropharynx

Heavy smokers and drinkers are subjects at risk of developing these cancers. Another risk factor is represented by infection of human papillomavirus (HPV). Cancers linked to HPV infection are typical of a young population (average age <50 years) and have better prognosis (better response to treatment). 

Diagnosis is easy, given accessibility to the tonsil region in the mouth. Biopsy under local anaesthesia is the most performed procedure. When the lesion occurs in the root of the tongue, difficult to access under local anaesthesia, biopsy is performed under general anaesthesia. The diagnosis of HPV-related cancer is made in conjunction with the histological diagnosis. Ultrasound, magnetic resonance, and PET (or even a total body CT) allow for correct staging.

Tumors of the hypopharynx

The risk factors are alcohol and tobacco abuse; the combination of these two factors increases the risk of hypopharyngeal cancer exponentially. Men, especially in the age range between 50 and 60, are more frequently affected. When present, symptoms are the sense of an external body in the throat, pain on swallowing, bad breath, stabbing pain to the ear, the presence of spots of blood in the saliva. In more advanced stages, the symptoms may be associated with changes in the voice, difficulty breathing, or swelling in the neck due to a metastatic lymph node which can often be the first sign of cancer. 

Diagnosis is made via a clinical and instrumental evaluation (fibre-optic video) in the clinic. It can be confirmed histologically by performing a biopsy of the lesion under general anaesthesia. Additional diagnostic tests such as CT, or magnetic resonance of the facial skeleton and neck, and PET complete staging to define in detail the spread of the disease before proposing the treatment, which in general depends on the stage.

Thyroid cancers

Risk factors are ionising radiation on the neck in the past and family history of hereditary thyroid cancer. The presence of pre-existing benign thyroid disease, hormonal factors, dietary intake of iodine 21 as well as dietary and environmental factors (smoking, solvents, dioxins, viruses) may also be risk factors. 

The typical clinical presentation is the single or multiple thyroid nodule accidentally retrieved from the patient himself or displayed in the neck ultrasound performed for other reasons. Other symptoms may include discomfort when swallowing in the thyroid site or non-specific neck pain.

Early diagnosis using ultrasound of the neck is very important to intercept tumours in early stage. This makes conservative therapies possible, especially in high-risk patients. Once a suspected thyroid nodule has been located, fine-needle aspiration is carried out under ultrasound guidance in order to define the cytological diagnosis. Blood tests for thyroid function and searching for tumour markers complete the diagnostic process. The treatment course can be planned according to the results.

Tumors of the parotid gland

Defining risk factors for rare tumours is not simple. In the case of the salivary glands it is known that exposure to radiation in the area of the head and neck (for a previous medical treatment) increases the risk.

These tumours appear as rarely painful  nodular masses (to be placed in differential diagnosis with the most frequent benign tumours) in the face, neck, or mouth. Dimorphisms may appear on the face (grimacing, changes in the shape and attitude) if the lesions affect the facial nerve (the nerve intended to the mimic muscles) or one of its branches.

For correct diagnosis an examination must be performed by a specialist with careful assessment of the medical and family history, and a targeted ultrasound examination allowing needle aspiration of a cell sample to be manoeuvred from the suspected areas, and the subsequent cytological diagnosis are required, which may also be repeated using needle biopsy technique for histological diagnosis. Additional radiological CT (computed tomography) and especially MRI (magnetic resonance) are considered second instance examinations, and are required by the specialist in selected cases.

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation.

Cancers of the oral cavities

Therapy is primarily surgery. The earlier the diagnosis, the lighter the surgery will be and the milder the consequences on functionality. In more advanced cases, larger removals are necessary, followed by sophisticated reconstructions through autografts, and rehabilitations of variable duration after surgery. Radiotherapy and chemotherapy are only used as complementary to surgery in selected cases, or as curative therapies in cases where surgery cannot be performed or when it is refused by the patient. 

At IEO, a new method has been developed for the surgical removal of the oral cavity and oropharynx tumours, called compartmental surgery, which allows an important prognosis improvement in over 400 cases of advanced tongue cancer treated.

Cancers of the larynx

The treatment of laryngeal cancer depends on the stage and place of occurrence. In tumours at an early stage, the recommended treatment is minimally-invasive surgery (laser microsurgery), that can be performed on an inpatient daily regime, in some cases. 

In advanced stages, therapy is typically multimodal. Cases are discussed in a multidisciplinary team and the most appropriate therapy, which is that giving the greatest assurance of cure with the least functional impairment (e.g. preservation of speech and swallowing), is then offered to the patient. Multimodal therapies may consist in conservative surgery followed by radiotherapy, or chemo-radiotherapy, or chemotherapy alone with the goal of preserving the organ and its functions.

Tumors of the nasopharynx

The treatment of nasopharyngeal cancer is solely radiotherapy in the early stages, and combined chemo-radiotherapy in more advanced stages. Surgery has a marginal role and is limited to the non-healed or relapsed lymph nodes in the neck, or to some cases of recurrent nasopharyngeal tumours refractory to further radiation treatment. 

Tumors of the oropharynx

The treatment of oropharyngeal cancers depends on a few factors such as the disease stage, site of occurrence and risk factors. In principle, in the initial stages treatment is single mode (radiotherapy alone or minimally invasive surgery), while in locally-advanced stages it is multimodal (chemo-radiotherapy, or surgery followed by radiotherapy or chemo-radiotherapy). 

Squamous cell carcinomas of the oropharynx, particularly if linked to HPV infection in non-smoking patients, have a good chance of cure with radio-chemotherapy treatment alone. The main side-effects of radio-chemotherapy treatments in the past were linked to the late effects of radiotherapy (dry mouth resulting in dental problems, difficulty in swallowing, jaw problems, hardening of the neck tissues). Modern techniques of radiotherapy (IMRT Intensity Modulated Radiotherapy) have allowed a better conformation of the dose to the target volume, with greater savings of the surrounding healthy tissues. This technological evolution has resulted in a reduction of late side-effects, in particular the incidence and severity of dry mouth.

A feasible alternative to radiotherapy in selected patients who have small localised tumours in particular in the region of the tonsil or base of the tongue, is mini-invasive endoscopic robotic surgery (robot-assisted surgery). The main advantage is a low incidence of side-effects and the ability to perform the treatment with a hospitalisation lasting a few days. In selected young patients having small localised tumours of the oropharynx in the tonsil region or at the base of the tongue, an alternative to radiotherapy is robotic surgery (robot-assisted minimally invasive surgery). The main advantage is a low incidence of side-effects due to a targeted and high precision intervention.

In selected cases, robotic surgery is applied to relapsed oropharyngeal cancers previously treated with radiotherapy or chemo-radiotherapy. When applicable, this surgery brings functional advantages over traditional surgery.

Tumors of the hypopharynx

The therapeutic treatment choice depends on various factors such as stage, site of the tumour and general health conditions of the patient. In cases diagnosed at the initial stage, it is possible to intervene with conservative methods such as radiotherapy or - in selected cases - minimally invasive surgical procedures using transoral laser microsurgery. On the contrary, in case of intermediate or advanced stage tumours, treatments combining chemotherapy and radiotherapy or more extensive surgery (total laryngopharyngectomy) need to be used, sometimes followed by post-operative radiotherapy or chemo-radiotherapy. 

Thyroid cancers

Surgery is the therapy of choice, performed by removing part of the gland (hemi-thyroidectomy) or the entire gland (total thyroidectomy), and eventually removing the lymph nodes in the central part of the neck and/or in the lateral loggias according to the stage of the disease. Once you know the definitive histological examination, in cases of well-differentiated tumours in advanced stage or with metastases in the cervical lymph nodes, the indication is for radionuclide therapy using iodine 131. Radiotherapy is also indicated in more advanced undifferentiated forms that do not respond to other therapies. With complete removal of the gland, replacement therapy with levothyroxine is prescribed from the day following the operation in order to replace the lack of thyroid hormone. 

For 20 years at IEO, hemi-thyroidectomy has been performed in early stage carcinomas retaining half of the thyroid gland, with results on the tumour equal to those obtained in other centres where the organ is usually completely removed. The use of more advanced equipment such as microscopic goggles and endoscopic optics support surgeons in magnifying the surgical field. Forceps and clotting scissors allow us to minimalise possible complications and the execution of the intervention through small incisions 2cm/3.5 cm MIVAT (Mini-invasive video-assisted thyroidectomy)/MIT (minimally invasive thyroidectomy).

In recent years at IEO, a surgical technique has been developed using natural dye under ultrasound guidance (USDAS = ultrasound dye-assisted surgery) allowing visualisation of very small pathological structures that are difficult to find (thyroid or disease residues and lymph node metastases) in the neck or in the areas that have already been operated on and characterised by altered anatomy and difficult localisation. At IEO, in cases where the disease has progressively developed in districts adjacent to the neck, especially at the level of the mediastinum in sites behind the sternum, surgery is supported by a collaboration between multiple specialists, in particular with thoracic surgeons for a complete multidisciplinary management.

Tumors of the parotid gland

The treatment of choice is surgery for tumours of the salivary glands (except for a few rare exceptions such as lymphoma). Surgery allows the removal of the tumour and some surrounding tissues and the lateral cervical lymph nodes (which may be the site of metastases), when necessary. Interventions are sensitive especially because of the presence of nerve structures in the salivary glands (the facial nerve and its branches). The surgical techniques are very advanced and use magnification (with a microscope and/or magnifying glasses) and facial nerve reconstruction when it has been damaged during the removal of the tumour. On the basis of the definitive histological examination, postoperative radiotherapy is prescribed in selected cases. 

When it is necessary to sacrifice the facial nerve (due to tumour infiltration), immediate reconstruction can be performed by transposing one or more segments of a donor nerve (great auricular, sural, latissimus dorsi). The donor nerve can be sacrificed because it does not imply major functional deficits. This technique can be practised in patients undergoing postoperative radiotherapy and allows recovery of face motility within 4-12 months. If for some reason immediate reconstruction cannot be performed, the patient may decide to undergo different types of delayed reconstruction.

Cancers of the skin and face

Removing a tumour of the face almost always requires a combined approach of curative surgery and reconstructive surgery; consider the importance of proper closing of the eyelids to protect the eye, or the function of the lips for speech and mastication, or the nose for breathing. 

Advanced tumours may require the intervention of the cervical-facial surgeon. This may be necessary when the tumour invades bone structure (jaw, cheekbone) or when infiltrating the skin it comes to affect the internal mucous membranes (cheek, nose). Some advanced tumours (such as spinal cell carcinomas) can cause metastases in the parotid gland or lymph nodes in the neck. In these cases, it may be necessary to add parotidectomy or lateral-cervical lymphadenectomy to the intervention for tumour removal.

Our multidisciplinary team (otolaryngologist, maxillofacial surgeon and plastic surgeon, physiotherapist, speech therapist) allows the treatment of the advanced skin lesions of the head and neck district with the best standards for reconstructive surgery.

• Multi-disciplinary, multicentre study on the role of HPV in head and neck cancers, HPV-related and non-related tumours; a study coordinated by IARC/WHO. (for detail on this study please visit: http://hpv-ahead.iarc.fr).
• IEO S629/411 (lymphatic mapping in oropharyngeal cancers; integration between Dynamic Lymphoscintigraphy and Fluorescence lymphography with indocyanine green     (ICG).
• IEO 804/13 OS (oncological and functional evaluation of head and neck cancer treated with robotic surgery. Real effectiveness and costs).
• IEO S720/412 (LUX-Head & Neck2-A randomised, double-blind, placebo-controlled, phase III study to evaluate the efficacy and safety of afatinib (BIBW 2992) as adjuvant therapy after chemo-radiotherapy in patients with squamous cell carcinoma of the head and neck, loco-regionally advanced, stage III, IVa or IVb, in the absence of primary surgery).
• IEO 801/13 F (cetuximab and cisplatin with or without paclitaxel in first-line treatment of recurrent/metastatic spinal cell carcinoma of the head and neck).
• IEO S398/208 (neoadjuvant chemotherapy with docetaxel, cisplatin and 5-fluorouracil (TPF) followed by radiotherapy plus concurrent chemotherapy or cetuximab compared to radiotherapy plus concurrent chemotherapy or cetuximab in patients with cancer of the head and neck, locally advanced. Factorial, randomised, phase III study).
• Robotic Surgery vs. radiotherapy alone in initial tumours of the oropharynx
• Surgical recovery of the neck after chemo/chemo-radiotherapy treatment.
• Treatment of patients with carcinoma of the larynx in the intermediate stage with induction chemotherapy followed by endoscopic laser resection.
• IEO N76/10 (Prognostic factors in the study of epidermoid carcinoma of the larynx).
• IEO N91/10 (predictive models of postoperative morbidity and length of hospital stay).
• IEO N73/10 (Role of conservative surgery in patients with laryngeal carcinoma pathologically advanced in stage III-IV).

Future and in progress studies.

1. Retrospective study on the evaluation of the prognostic value of EGFR expression in patients treated with surgery and postoperative radiotherapy for cancers of the cervical-facial district.
2. Prospective study on the evaluation of acute dysphagia in patients treated with radiotherapy.
3. Cyberknife treatment in the head and neck district, retrospective analysis of the IEO experience.
4. Early nutritional counselling in patients treated with radiotherapy for head and neck tumours: the European Institute of Oncology experience, preliminary results.
5. Impact of low doses on the ocular structures in patients treated with IMRT in the head and neck region (nasopharynx, parotid gland).
6. IMRT in patients undergoing conservative surgery for locally advanced cancer of the larynx, prospective, observational study.
7. Smoking and tolerance to radiotherapy, prospective, observational study.
8. A multicentre randomised open trial to evaluate the efficacy of fentanyl pectin nasal spray (FPNS) versus Physician Choice (PC) - Usual Care (UC) in reducing incidental predictable breakthrough pain (IP-BTP) at swallowing in patients with head and neck cancer undergoing radiotherapy.
9. Phase II, clinical trial on radiotherapy boost using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic district (collaboration with CNAO, National Centre of Oncology Hadrontherapy)

Cancers of the oral cavities 

 Particular attention is paid to the reconstruction of post-surgical defects. The experience of more than 600 autografts of micro-vascularised flaps and the development of new models of functional reconstruction put us as leaders in this field.

Cancers of the larynx 

Rehabilitation phase after treatment is essential for improving the quality of life. The voice and speech service takes patients in charge before treatment and follows them throughout the rehabilitation process. 

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.

Artificial Nutrition (AN) is indicated in cases of cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicate oral feeding), or in the case of evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, prevent dehydration and interruptions of the radio-chemotherapy treatment, reduce the frequency and duration of hospitalisations, and improve the quality of life.

Adequate nutritional support during radiotherapy treatment can reduce the impact and degree of morbidity (mucositis, odynophagia, dysphagia, xerostomia, dysgeusia, nausea, vomiting, and anorexia), minimise weight loss, preserve the nutritional status, improve the quality of life and optimise by speeding it up the recovery of the patient at the end of treatment.

The use of early and intensive nutritional counseling and oral caloric supplementation have been shown to increase the protein-calorie oral intake, reduce the extent of body weight loss, and reduce the interruptions of the cancer treatment.

In the presence of a sufficiently safe swallowing, oral feeding (using a diet modified in consistency) is the first choice.