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REVIEW ARTICLE
Management of Head and Neck Cancer: Surgical
and Nonsurgical
1Arsheed Hussain Hakeem, 2Sultan Pradhan
11Consultant, Head and Neck Surgeon, Department of Surgical Oncology, Prince Aly Khan Hospital, Mumbai, MaharashtraIndia
22Chief of Oncology Services, Prince Aly Khan Hospital, Mumbai, Maharashtra, India
Correspondence: Arsheed Hussain, Consultant, Head and Neck Surgeon, Department of Surgical Oncology, Prince Aly KhanHospital, Nesbit Road, Mazagaon, Mumbai-4000010, Maharashtra, India, e-mail: drahhakim@gmail.com
 
Abstract
It is right time to review the management of head and neck squamous cancer (HNSC) because of fundamental changes in bothdiagnostic and therapeutic modalities. Head and neck cancer affects area highly associated with the individual�s.
identity and can produce profound alteration in appearance, speech, and swallowing. Due to morbidity, disfigurement and problems ofdisease control clinicians used to have lot of reservations in treating complex HNSC cases. The field has taken a new vigor byincorporating important basic advances in understanding of cancer, new modalities of treatment and management of functional deficits.Although much progress has been made in understanding the molecular genetics of HNSC for novel diagnostic and therapeuticinterventions, they are still far to go before becoming standard of care for head and neck cancer.
Keywords: Oral squamous cell carcinoma, surgical management.
 
The anatomic and functional complexity of the head andneck region and the invasive nature of the disease maketheir management extremely challenging. Multidisciplinaryapproach that encompasses surgical, medical and ancillaryexpertise should be adopted. This approach necessitatesnot only adequate resection of the tumor but also timelyreconstruction and adjuvant treatment. A comprehensivehead and neck surgery team would consist of a head andneck surgeon, medical oncologist, reconstructive surgeon,neurosurgeon, radiation oncologist, prosthodontist andnutritionists experienced in head and neck oncology.

MANAGEMENT

The management of head and neck cancer begins withcomprehensive history and complete head and neckexamination, which includes an office-based endoscopy forevaluation of upper aerodigestive tract (UADT). A numberof treatment options are available like surgery, radiotherapy,chemotherapy or combination of these. Choice of initialtreatment modality depends on site and stage of tumor(Tumor factors), factors related to the patient (Patientfactors) like physical and social status. Institutional factorslike resources, expertise and treatment philosophy adoptedby multidisciplinary team also play important role.
  ORAL CAVITY

Surgery is the modality of choice in treating early stagedisease of oral cavity (i.e., stages I and II). Althoughradiotherapy (RT) is equally effective in treating earlycarcinoma of oral cavity, surgery as single modality ispreferred for following reasons:
  1. Surgery requires less treatment time as compared toradiotherapy.
  2. It holds radiotherapy in reserve for the treatment siteswhich are not amenable to surgical treatment in case ofsecond primary of UADT.
  3. Helps to avoid significant morbidity like xerostomia anddysphagia.
  4. Locoregional control rates are similar to the radiotherapyalone.
Defects usually left after resection of the early oral cavitycancers do not require extensive reconstructive techniques.They can be closed primarily, or skin grafted or left forgranulation. Surgery is combined with postoperativeadjuvant radiotherapy or chemoradiotherapy in advanceddisease (stage III and IV). Wide excision of tumor in alldimensions with adequate margins and appropriate neckdissection is essential in local-regional control of disease.Adjuvant radiotherapy or chemoradiotherapy improves loco-regional control and disease free
 
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Arsheed Hussain Hakeem, Sultan Pradhan
 
survival.1 Chemotherapyin neoadjuvant setting has shown promise; however, itsuse is presently limited to institutional trials.2
The factors that influence the choice of surgical approachfor a primary tumor of the oral cavity are the size of theprimary, its depth of infiltration, the site of the primary (i.e.anterior or posterior, location), proximity/invasion of thetumor to the mandible or maxilla, dentition, presence orabsence of trismus, expertise and preference of individualsurgeon.
Various surgical approaches for oral cavity lesions are:
  1. Peroral
  2. Mandibulotomy (midline /Paramedian)
  3. Lower cheek flap
  4. Visor flap
  5. Upper cheek flap.
Small primary tumors of the oral tongue, floor of mouth,gum, cheek mucosa and hard or soft palate are suitable forperoral excision (Figs 1A and B). T3 and T4 lesions oftongue with deep infiltration or crossing midline are resectedwith mandibular swing or lingual release.3,4 Main advantageof the lingual release over mandibulotomy is avoidance ofthe mandibular osteotomy with its complications of malunionor nonunion which occur more in radiated patients.5 Careshould be taken to place osteotomy site between the toothroots, however if there is dental crowding extraction ofone tooth is preferred. Orthopantomogram usually assistsin planning the osteotomy site. Commercial availability ofmini plates has improved reconstruction of the mandiblewith reduced morbidity.

MANAGEMENT OF MANDIBLE

Invasion of the mandible has significant implications forboth prognosis and postoperative rehabilitation. Presentlythere is no imaging modality that provides accurateassessment of the early bone invasion. A combination ofthe orthopantomogram and CT scan has high sensitivity(81%) and specificity of (88%).6 SPECT and MRI havealso shown promise with sensitivity of 90% but their limitedavailability curtails their routine use.7 Early mandibularinvolvement is difficult to detect preoperatively. Ourapproach to the evaluation of the mandible includes highdegree of suspicion, 3-dimensional CT (Fig. 2) scan andassessment of the mandibular periosteum at the time ofresection.
If there is gross involvement of the mandible clinicallyand radiologically the standard of care is segmentalmandibulectomy (Fig. 3) and preferred reconstruction forsuch lesions is vascularized�osseous free tissue transfer. But in certain elderly edentulous cases where lesions arelocated posteriorly  it  can  be  left  unreconstructed
 
FIGURE 1A: Clinical picture showing T1 lesion


FIGURE 1B: Clinical specimen of T1 lesion tongue done perorally

withacceptable cosmetic results. Most of the clinicians are indilemma when the lesions are close or about the mandible.We prefer to do a marginal mandibulectomy and it is widelyaccepted approach when there is no clear evidence of boneerosion.8 This operation involves partial resection of themandible, i.e either the superior half (Fig. 4) of the mandibleor the lingual cortex. Locoregional control and survival ratescompare well to that of the segmental mandibulectomy.9,10Bone height should be assessed before embarking on theprocedure of marginal mandibulectomy. Edentulous patients seem to have decreased bone height and  less  resistance  to the  advancing  tumor
 
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Management of Head and Neck Cancer: Surgical and Nonsurgical
 

FIGURE 2: 3D CT reconstruction with erosion of lingual cortex ofleft mandible


FIGURE 3: Segmental mandibulectomy specimen withulceroinfiltrative lesion eroding lingual cortex of mandible

front. Once invasion of theneurovascular canal has occurred the tumor tends to spreadto the skull base along the inferior alveolar nerve. In such asituation we prefer to do a hemimandibulectomy withresection of the inferior alveolar nerve as high as possible.
Special mention needs to be made of the gingival �buccalcancers in Indian population because of the peculiar habitof keeping the tobacco quid in the lower gingivobuccalsulcus. On one hand there may be early lesion (Fig. 5) whichmay need just mucoperiosteal stripping
 
FIGURE 4: Marginal mandibulectomy defect after removal of upperof mandible along with buccal mucosa

while on the other hand full thickness cheek composite resection is requiredfor the advanced lesions (Figs 6 to 7B). Reconstruction insuch huge defects can be accomplished by bipaddlepectoralis major myocutaneous flap (Fig. 8) or bipaddlefree tissue transfer like anterolateral thigh or rectus abdominisfree flap.

Neck

The management of clinically N0 neck is still controversialand depends on the approach to the primary lesion. N0neck both clinically and on USG examination can beobserved or electively dealt by selective neck dissection.Supraomohyoid neck dissection (clearance from level I toIII) is indicated if USG suspicious, thick lesion, cheek flapis raised for approach and poor follow is expected. If frozensection is positive completion modified neck dissection isrequired. N+ needs to be addressed by modified or radicalneck dissection depending on nodal status. Bilateral neckneeds to be addressed if the primary disease is in midline orextending across midline (including middle third mandible).However, "skip metastasis" involving Level III and LevelIV is well-known in oral tongue cancers in up to 15% ofpatients. In addition, adjuvant radiotherapy is recommendedif occult disease is identified.
 
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FIGURE 5: Early lower gingivobuccal cancer


FIGURE 6: T4a (fungating) gingivobuccal carcinoma

ORO PHARYNGEAL CANCERS

The treatment of or pharyngeal carcinoma is aimed atmaximizing cure with least possible functional morbidity.Therefore T1and T2 lesions are treated with radicalradiotherapy and chemoradiotherapy is the treatment ofchoice in advanced T3, T4 tumors. Some early, lateral placedand verrucous lesions can be resected only if surgicalresection is associated with reasonable functional outcome.It is also preferred with postoperative radiotherapy in selectadvance cases, e.g. infiltrative lesions of base tongue, tonsil and lesions involving the
 
FIGURE 7A: T4a lesion of the lower gingivobuccal sulcus


FIGURE 7B: Axial CT scan oral cavity showing gross erosion ofthe middle third of the mandible.

mandible and as a salvage procedurefor residual neck nodes following chemoradiotherapy.

Soft Palate

Soft palate tumors relatively uncommon and becomesymptomatic once tumor achieves substantial size. Overall5-year rate survival with unilateral disease is 70.8% anddrops to 51% with midline or bilateral lesions.11 Very smalllesions of soft palate, especially of uvula can be resectedperorally with out much functional disability. But larger lesion
 
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Management of Head and Neck Cancer: Surgical and Nonsurgical
 

FIGURE 8: Clinical picture showing large defect reconstructedusing bipaddle pectoralis major myocutaneous flap

involving significant areas are treated with radiotherapy sincethe morbidity of initial surgery is significant. Surgicaltreatment of even small lesion results in a large defect withfunctional difficulties. Even radiotherapy leaves a palataldefect which can cause nasal escape and regurgitation, theassociated morbidity is usually better than after resection.Advanced soft palate lesion have poor prognosis.

Tonsillar Complex

Asymptomatic nature of this disease causes many patientsto present in T3 and T4. Since surgical resection of thetonsillar complex cancers offers no curative advantage,irradiation largely has become the first line treatment forearly tonsillar carcinomas. Morbidity is minimized andreserves the surgery for salvage. It has improved 5-yeardisease free survival to 85 to 100% for T1 lesions and 80 to90% for T2 lesions.12 The treatment approach for the T3and T4 tonsillar carcinomas that provides the greatest chanceof cure is combined surgery and radiotherapy. Debatecontinues if the surgery is to be used upfront or for salvage.In order to minimize significant morbidity associated withmajor resection of the oropharynx, chemoradiotherapy withsurgical salvage has been advocated. Important disadvantagewith the radiotherapy up front is that it changes the sensitivityof clinical examination to the extent that early detection ofthe residual or recurrent disease may not be possible andonce detected the disease may have extended beyond thescope of surgical resection. If radiotherapy fails to controlthe disease less than 25% patients are salvagablesurgically.13,14
  Tonsillar Complex

Most of the centers favor the use of radiation or chemoradiationfor early (T1and T2) base of tongue. Patients withexophytic growths, significant comorbidities, not willing toaccept functional deficits of subtotal or total glossectomyare best treated to radiotherapy or chemoradiotherapy,reserving surgery for salvage. In patients with ulceroinfilterativetumors, infiltration of deep musculature and largevolume disease crossing midline the best chance of achievinglocoregional control is radical surgery followed by adjuvantchemoradiation. Tumors that extend to the supraglottis mayrequire supraglottic laryngectomy or even total laryngectomy.Alternate approach to such lesion is chemoradiotherapy.This approach avoids mutilating surgery whichoften is futile exercise.
Reconstruction of such defects is usually accomplishedby pedicled pectoralis major myocutaneous or free tissuetransfer from anterolateral thigh or rectus abdominis flap.

LARYNGEAL CANCER

The goal of treating laryngeal cancer should focus onadequate oncologic chance of cure while attempting tominimize the morbidity. It is head and neck surgeon�s dutyto evaluate all laryngeal cancer patients for organpreservation from their initial visit. Certain key principlesshould be strictly adhered to in determining the patient�seligibility for open organ preservation surgery.
  1. Organ preservation surgical procedure should beemployed when complete (R0) resection of the tumorcan be accomplished.
  2. Confident prediction of the extent of the tumor. Diligentendoscopy, dynamic study of larynx and CT scan aid inmapping the lesion accurately.
  3. Cricoarytenoid joint is the functional unit of the larynx.It consists of the arytenoid and cricoid cartilages withassociated musculature and superior and recurrentlaryngeal nerves for that unit should be preserved.
  4. A chronic and inefficient cough and inability to walk uptwo flights of stairs without breathlessness indicate poorability of the patient to tolerate organ preservationsurgery.
Transoral Laser Resection

Early laryngeal cancer is curable disease with single modalitytherapy of radiation or surgery. Surgery for the early cancerof the larynx has evolved from partial open laryngectomyto the endoscopic laser
 
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Arsheed Hussain Hakeem, Sultan Pradhan
 
resection. Laser resection hasprovided a paradigm shift in the treatment of early laryngealcancer. After Steiner�s15 landmark report in1993, transorallaser resection has become established treatment option forearly laryngeal cancer. Endoscopic resection of early cancerprovides an acceptable cure rates provided close follow-upis possible and appropriate adjuvant therapy is providedwhen indicated. Laser resection often uses piecemealresection compared with the standard en bloc resection.This is possible because of the use of magnification of themicroscope and characteristic properties of the CO2 laser.Several studies have reported local control rates for T1 andT2 disease in the range of 77 to 92% and 66 to 88%respectively.16-18 Most patients only need overnight stay,tracheotomy is completely avoided, aspiration is not at allsignificant problem and tube feeding if required is usuallyfor dysphagia and that too for few days. Other potentialcomplications of open surgery like wound dehiscence,infection, emphysema, cutaneous fistulas is rare.
Transoral laser resection is not indicated for the surgeonwithout experience, training and skill in the endoscopicapproaches.

Conservative Laryngeal Surgery

Indications for conservative surgical procedures havechanged because of the endoscopic CO2 laser surgery andchemoradiation protocols for organ preservation. For us,the indications for open conservation surgery in patientshistorically felt to be candidates for this approach are:
  1. Early laryngeal cancer where endoscopic exposure isinadequate.
  2. Patients with anterior commissure cancer who failradiotherapy.
  3. Young patient where radiotherapy needs to be avoided.
  4. T2b glottic cancers.
  5. Cancer of posterior larynx where full arytenoidectomyis needed.
Laryngofissure with cordectomy entails resection ofvocal fold through thyrotomy. This procedure is indicatedfor mid third mobile vocal fold lesions. Vertical partiallaryngectomy can be successfully used for lesions withoutinvolvement of the anterior commissure. Other select T1andT2 lesions including cancers involving anterior commissureare treated with frontolateral hemilaryngectomy orsupracricoid laryngectomy (SCPL). Frontolaterallaryngectomy removes vocal fold,
  anterior commissure, andanterior third of the vocal cord and overlying thyroidcartilage. SCPL preserves at least one cricoarytenoid unit.A five years disease specific survival rate 92 to 97% isreported for T1 and T2 lesions.
For advanced glottic carcinoma, T3 and T4, the localcontrol rates for radiation therapy range from 40 to 60%.Local control rates for surgery are greater ranging from 84to 96%, and the 2 years disease free survival is 79% for T3and 58% for T4. Combination therapy is usually superior tothe single modality alone. Total laryngectomy is the goldstandard. While near total laryngectomy (NTL) by Pearson19and supracricoid partial laryngectomy by Kitamura permitsextirpation of the advanced cancer of the larynx and can beused in certain cases. The Pearson�s procedure does noteliminate the need of permanent tracheotomy, however bothrequire careful patient selection and advanced surgicalexperience and skill. NTL is most suitable for resection ofunilateral T3 and T4 laryngeal cancer or transglottic cancerwithout involvement of the interarytenoid region. One shouldbe able to preserve at least one thirds of the contralateralcord so that a functional voice shunt can be formed afterresection.
Surgery is preferred in supraglottic lesions in case oflarge volume disease, cartilage erosion, bulky nodes, grosspre-epiglottic space invasion and comorbidity not permittingchemoradiation.
Primary subglottic cancer is rare. Most of the lesionsare extension from the glottic area. Presence of the diseasein the subglottic space increases the risk of the paratrachealnodes and extralaryngeal spread. It is recommended thattotal laryngectomy, thyroidectomy, and paratracheal nodalclearance should be done followed by adjuvant radiotherapyor chemoradiotherapy for advanced lesions.

HYPOPHARYNGEAL TUMORS

Despite advances in the surgical and nonsurgical treatment,overall survival rates have not improved for patients withhypopharyngeal cancers. Surgery and radiotherapy as asingle modality have similar results in stage I and II disease.However, radiotherapy is preferred over surgery due to itslow morbidity and voice preservation. In stage III and IVdisease, surgery plus postoperative radiotherapy andchemoradiotherapy have shown equal results regardingsurvival. Due to higher chance of laryngeal preservation,Chemoradiotherapy should be offered to patients with lowvolume disease. The best results are with combination of surgery and radiotherapy and two thirds of patients arepalliated if not cured of the disease.
 
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Surgical Treatment

Hypopharyngeal cancers are unique in demonstrating highpropensity for submucosal spread of the disease. TransoralCO2 excision is advocated for early lesions of pyriformand posterior pharyngeal wall, particularly in Germany.20These lesions are resected with margin of 5 mm for smallercancers and 10 mm for larger ones. Cases selection shouldbe done properly. Only superficially infiltrative cancers withmobile vocal cords are suited for the resection. Thetechnique is not widely performed because it is technicallydifficult and to perform and requires special expertise. Larynxpreservation without jeopardizing survival appears feasiblein patients with T3/T4 cancer of the hypopharynx. Surgeryis the treatment of choice inpatients with large volumedisease, bulky neck nodes, cartilage erosion, extensive softtissue involvement. Near-total laryngectomy/Totallaryngectomy with partial pharyngectomy followed byadjuvant chemoradiotherapy is the usually required for suchlesions. Reconstruction of defect depends on mucosal defect.If stretched mucosa is 3 cm primary closure is feasible, ifmucosa inadequate � patch PMMC or free radial forearmflap is advocated.
T1 and T2 lesions of the postcricoid and posteriorpharyngeal wall are best treated with radical radiotherapy.T3-4 Any N Large volume disease needs total laryngopharyngoesophagectomywith gastric pullup or free jejunalflap (Figs 9A to D) or tube pectoralis myocutaneous flapand postoperative radiotherapy.

Chemoradiotherapy for Laryngeal Preservation

Organ preservation in stage III/IV laryngeal/hypopharyngealcancers seemed a reality with the landmark veterans affairslaryngeal study group21 and EORTC trials.22 The Inter-groupstudy further strengthened these findings. As of todaychemoradiotherapy should be considered the standard ofcare for small volume stage III/IV laryngeal andhypopharyngeal cancer. This has resulted in preservationof organ that otherwise would have required totallaryngectomy without compromising survival. A decreasedincidence of distant metastasis was seen in the organpreservation group compared with the surgery group (25%vs 36%). The 5 year estimate of other retaining the functionallarynx for chemoradiation was 35%. Similar data has beenreported by the institutions.22,23
More recently, concurrent chemoradiotherapy, the simultaneous use of chemotherapy and radiotherapy has been used to take advantage of radiation enhancer. Concurrent treatment with chemotherapy potentially treats distant disease and locoregional disease and may
  improvesurvival rates. Although organ preservation is possible, butpreserved organ is not always functional. Acute side effects,particularly mucositis are more severe with the concurrentthan neoadjuvant treatment .Significant laryngeal andpharyngeal dysfunction has been reported followingchemoradiation. Pretreatment vocal cord fixation seems tobe the strongest predictor of poor functional outcome, withmore than 50% requiring a feeding tube or tracheotomy 6months after the completion of therapy compared with thepatients without vocal cord fixation.


FIGURE 9A: Clinical photograph after total laryngopharyngoesophagectomy


FIGURE 9B: Clinical picture of the free uenai segment to be usedfor reconstruction
 
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Arsheed Hussain Hakeem, Sultan Pradhan
 

FIGURE 9C: Clinical picture depicting pharyngeal reconstructiondone using free jujenun


FIGURE 9D: Clinical picture showing part of the free juenum keptoutside for monitoring

PARANASAL SINUS TUMORS

Management of the paranasal sinus tumors is challengingbecause of the surrounding vital structures like orbit and
  brain. The goal of the surgical resection is en bloc removalof the tumor with margins clear of neoplastic cells. Totalmaxillectomy is the standard procedure for maxillary sinuscancer. Numerous modifications like medial maxillectomy,infrastructure maxillectomy, subtotal maxillectomy andradical maxillectomy may be used depending on the tumorextent. Neoplasm involving ethmoids frontal and sphenoidsinuses will need craniofacial resection because of the skullbase involvement. Surgical resection therefore remains theinitial treatment of choice for nearly all sinonasal tumorsexcept those which are felt to be categorically unresectable.Surgical treatment alone is considered appropriate for nearlyearly staged malignant tumors amenable to a curative surgicalresection. Criteria of unresectiblity are:
  • Gross infiltration of infratemporal fossa.
  • Pterygoplatine fissure involvement.
  • Involvement of dura and intracerebral extension ofsquamous carcinoma.
  • Cavernous sinus involvement.
  • Involvement of sphenoid.
  • Extensive soft tissue and skin infiltration.
  • Bilateral orbital involvement.
On the other hand, unresectable tumors are currentlytreated by a simultaneous treatment program of systemicchemotherapy and hyper fractionated radiotherapy withpromising early results.
Although the use of endoscope has many advantageslike lack of skin incision and lower morbidity as comparedto open approach. The endonasal approach should be limitedto tumors without extensive involvement of sinuses, orbitor cranial base.

Treatment of Neck

N0 neck both clinically and radio logically should beobserved. Appropriate neck dissection and postoperativeradiotherapy to both necks should be done for dependingon nodal status. Microvascular free tissue transfer forextensive skin and soft tissue defect, orbital exentration,skull base reconstruction and if more than half of the palateneeds to be resected.

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