Surgical treatment in head and neck cancer

Three topics currently important in head and neck surgery are voice-conserving surgical treatment of laryngeal cancer, the role of modified radical neck dissection in the treatment of cervical metastases, and reconstruction and rehabilitation of the head and neck cancer patient. The laser has become an accepted modality for the treatment of early vocal cord cancer and has local control rates comparable to other treatment methods. Partial laryngectomy can conserve voice and yield excellent local control rates. The modified radical neck dissection has been shown to yield rates of local recurrence no greater than radical neck dissection for N0 and N1 neck disease associated with laryngeal cancer. Vocal rehabilitation following total laryngectomy has been revolutionized by the tracheoesophageal puncture procedure. Most patients can be expected to acquire voice using tracheoesophageal puncture following total laryngectomy. Free flaps have improved the functional results of many major head and neck surgical procedures and offer the possibility of better results in the future. However, more conventional reconstructive techniques, including local flaps, continue to have a role in head and neck surgery.     

头颈肿瘤颈淋巴结清扫的手术选择

作为治疗与预防头颈恶性肿瘤颈部淋巴结转移的首要方法,颈淋巴结清扫术经过一百多年的发展,已经日趋规范合理。但是,由于头颈恶性肿瘤的种种特殊性导致其颈部淋巴结转移有较大的不确定性,头颈外科医师在施行原发灶手术时,往往会面临是否需要行颈淋巴结清扫术、如何确定颈淋巴结清扫范围的困惑。根据常见头颈恶性肿瘤的颈淋巴结转移特性及手术对患者的创伤程度,梳理出当前较为规范的颈淋巴结清扫术术式,为头颈外科医师提供参考,有助于改善头颈恶性肿瘤颈部淋巴结治疗和预防的总体效果。     

Controversies in management of the neck in head and neck cancer

Opinion statement As definitive external radiation and multimodality organ preservation strategies (eg, combined chemotherapy and radiation therapy [CCRT]) improve, the role of surgery is being re-examined in the management of locally advanced head and neck cancer. Consensus regarding the use of neck dissections for complete responders and incomplete responders has yet to be achieved and the data are surprisingly controversial. A possible benefit from neck dissection after a complete response of the primary tumor after CCRT or definitive external radiation for advanced squamous cell carcinoma of the head and neck may only be anticipated in patients with persisting subclinical neck disease who have no other sites of disease. Some clinicians have even argued that the salvage rate for clinically detectable residual neck disease does not justify neck dissection. Randomized data addressing these questions and a trial addressing the accuracy of new imaging modalities, such as postchemotherapy and postradiation positron emission tomography scanning, across multiple institutions would be appropriate. As a department, we are aggressive in our treatment of isolated residual neck disease after CCRT or definitive external radiation and for patients initially diagnosed with N3 nodal disease. We are investigating the use of adjuvant neck brachytherapy at the time of neck dissection and we are pleased with our early results.     

Place du curage ganglionnaire après chimioradiothérapie dans les carcinomes épidermoïdes des voies aérodigestives supérieures avec atteinte ganglionnaire initiale (nasopharynx exclu)

The optimal timing and extent of neck dissection in the context of chemoradiation for head and neck cancer remains controversial. For some institutions, it is uncertain whether neck dissection should still be performed upfront especially for cystic nodes. For others, neck dissection can be performed after chemoradiation and can be omitted for N1 disease as long as a complete response to chemoradiation is obtained. The question is debated for N2 and N3 disease even after a complete response as the correlation between radiological and clinical assessment and pathology may not be reliable. Response rates are greater than or equal to 60% and isolated neck failures are less than or equal to 10% with current chemoradiation protocols. Some therefore consider that systematic upfront or planned neck dissection would lead to greater than or equal to 50% unnecessary neck dissections for N2-N3 disease. Positron-emission tomography (PET) scanning to assess treatment response and have shown a very high negative predictive value of greater than or equal to 95% when using a standard uptake value of 3 for patients with a negative PET at four months after the completion of therapy. These data may support the practice of observing PET-negative necks. More evidence-based data are awaited to assess the need for neck dissection on PET. Selective neck dissection based on radiological assessment and peroperative findings and not exclusively on initial nodal stage may help to limit morbidity and to improve the quality of life without increasing the risk of neck failure. Adjuvant regional radiation boosts might be discussed on an individual basis for aggressive residual nodal disease with extracapsular spread and uncertain margins but evidence is missing. Medical treatments aiming at reducing the metastatic risk especially for N3 disease are to be evaluated.     

Necessity for adjuvant neck dissection in setting of concurrent chemoradiation for advanced head-and-neck cancer

PURPOSE: Neck dissection has traditionally played an important role in the treatment of patients with squamous cell carcinoma of the head and neck who present with regionally advanced neck disease (N2-N3). Radiotherapy and concurrent chemotherapy improves overall survival in advanced head-and-neck cancer compared with radiotherapy alone. The necessity for postchemoradiation neck dissection is controversial. The intent of this report was to define the value of neck dissection in this patient population better. METHODS AND MATERIALS: Patients with locally advanced squamous carcinoma of the head and neck who also presented with nodal disease and underwent hyperfractionated radiotherapy and concurrent cisplatin/5-fluorouracil chemotherapy constituted the study population. Adjuvant modified neck dissection (MND) was planned 6 to 8 weeks after completion of chemoradiation in those patients who had a biopsy-proven pathologically complete response at the primary tumor site, irrespective of the clinical/radiographic neck response. A cohort of patients underwent electrode assessment of tumor oxygenation. Pathologic findings from the MND were used to compute the negative and positive predictive values and overall accuracy of the clinical/radiographic response (cCR). Regional control, failure-free survival, and survival were compared according to whether patients actually underwent MND. RESULTS: A total of 154 patients received concurrent chemoradiation. Of these, 108 presented with nodal disease: N1, n = 30; and N2-N3, n = 78. MND was performed in 65 (60%) of 108 patients, including 13 (43%) of 30 with Stage N1 and 52 (66%) of 78 with Stage N2-N3. For N1 patients, the negative predictive value of a cCR, positive predictive value of less than a cCR, and the overall accuracy for clinical response was 92%, 100%, and 92%, respectively. For N2-N3 patients, the corresponding values were 74%, 44%, and 60%. Patients with poorly oxygenated tumors were more likely to have residual disease at MND. The median follow-up was 4 years. The 4-year disease-free survival rate was 70% for N1 patients, irrespective of the clinical response or whether MND was performed. The 4-year disease-free survival rate was 75% for N2-N3 patients who had a cCR and underwent MND vs. 53% for patients who had a cCR but did not undergo MND (p = 0.08). The 4-year overall survival rate was 77% vs. 50% for these two groups of patients (p = 0.04). CONCLUSION: The clinical and pathologic responses in the neck correlated poorly with one another for patients with N2-N3 neck disease undergoing concurrent chemoradiation for advanced head-and-neck cancer. MND still appears to confer a disease-free survival and overall survival advantage with acceptably low morbidity. Tumor oxygenation assessment may be useful in selecting patients who are especially prone to have residual disease. Better tools need to be developed to determine prospectively whether this procedure is required for individual patients.     

Sentinel lymph node biopsy in head and neck cancer

In the past decade, the technique of sentinel lymph node biopsy (SLNB) has been applied to a vast array of primary neoplasms, ranging from head and neck melanoma to vulvar carcinoma. At present, experience with SLNB is greatest in patients with melanoma and breast cancer. In view of the well known complications associated with cervical node dissection, it has been suspected for some time that cervical SLNB, if successful, might reduce the morbidity associated with the definitive care of patients with head and neck cancers. This report assesses the current status of SLNB in the treatment of head and neck cancers; while formal investigations of the efficacy of this technique are recommended, SLNB has not yet been demonstrated to possess the same level of utility seen in SLNB in melanoma and breast cancer patients. As a consequence, the application of SLNB to head and neck cancers remains an experimental technique--one which has not yet acquired the status of the standard of patient care.     

肿瘤侵犯颈动脉时的颈淋巴清扫术及相关处理

目的 探讨肿瘤侵犯颈动脉时的颈淋巴结清扫手术方法。方法 对3例头颈部恶性肿瘤晚期颈淋巴结转移颈动脉可能受侵患者，行颈动脉间断结扎术。结果 间断结扎可有效促进对侧脑血管代偿形成，为进一步进行颈清扫手术提供安全保障。结论 肿瘤侵犯颈动脉并非绝对手术禁区,先期采用颈动脉结扎等处理可取得较满意效果。     

Larynx-sparing radiotherapy for squamous cell carcinoma from an unknown head and neck primary site

The objective of this study was to evaluate the efficacy of larynx-sparing radiotherapy (RT) alone or in combination with a neck dissection for patients with squamous cell carcinomas metastatic to cervical lymph nodes from an unknown head and neck primary site. Seventeen patients were treated with curative intent between 1997 and 2002; 16 of 17 patients had follow up for at least 2 years. No patient developed a squamous cell carcinoma in a head and neck mucosal site after treatment. One patient (6%) had persistent nodal disease and 1 patient (6%) had recurrent nodal disease 1 year after completing RT. No patients experienced distant metastases. The 5-year cause-specific and overall survival rates were 88% and 82%, respectively. Based on our limited experience, larynx-sparing RT appears to result in a high likelihood of local-regional control and survival and likely reduces both acute and late toxicity.     

Functional imaging in head and neck cancer

Functional imaging has become an increasingly important diagnostic tool for head and neck cancer, and as its availability increases so will its utilization. Positron emission tomography (PET) with the radiotracer 18-fluorodeoxyglucose (¹⁸FDG) is the most commonly used functional imaging technology, and it has the potential to improve the staging and detection of head and neck tumors compared with conventional cross-sectional imaging techniques such as CT or magnetic resonance imaging. Specifically, PET contributes valuable information for localizing a primary tumor in patients with an unknown primary and neck metastasis, in the staging of untreated head and neck cancer, in the detection of residual disease after definitive radiotherapy or chemoradiotherapy, and in the detection of recurrent disease. New technologies have been introduced using the combination of CT and PET, which allows exact anatomic correlation with areas of increased tracer uptake. In addition, new tracers may allow quantification of important cellular processes related to tumor proliferation or identification of tumors that may respond to certain targeted therapies. This strategy will eventually enable physicians to tailor therapy to molecular characteristics and therefore improve outcomes for patients with head and neck cancer.     

The expanding role of dental oncology in head and neck surgery

A comprehensive dental oncologic screening should be part of the pretreatment workup of patients who have head and neck cancer. This screening should be performed by a dentist who is familiar with the pathologic process of disease and type of treatment being rendered; in addition, he or she should comprehend the various morbidities associated with eradicating head and neck malignancy. The dental oncologist must provide the timeline for the surgeon and radiation oncologist in which all necessary dental treatment will be completed. It is important at this juncture to educate the patient as to the possible short- and long-term complications,no matter what treatment course they choose.Osseointegrated implants used in the rehabilitation of patients who have undergone head and neck surgery have provided a more reliable means of retaining intraoral and extraoral prostheses. With close communication between the head and neck surgeon and dental oncologist, and careful patient selection, better functional outcomes may be provided.     

Squamous cell carcinoma of the head and neck treated with radiation therapy: the role of neck dissection for clinically positive neck nodes

This is an analysis of 161 patients with squamous cell carcinoma of the head and neck treated with irradiation to the primary site and neck followed by a neck dissection(s) for clinically positive neck nodes. Patients were treated between October 1964 and December 1982; there was a minimum 2-year follow-up. Fifty-two patients were deleted from analysis of neck disease control because they died of intercurrent disease or cancer less than 2 years from treatment with the neck continuously disease-free. All patients are included in the analysis of complications. Neck disease control rate was the same for radiation plus neck dissection or radiation therapy alone for solitary nodes less than 3 cm. As the size and number of nodes increased, there was a higher rate of neck disease control for combined treatment as compared with irradiation alone. The neck disease control rate, size for size, was lower for patients with fixed nodes and for those with residual tumor in the pathologic specimen. There was no difference in neck disease control as a function of the interval between irradiation and neck dissection. For nodes less than or equal to 6 cm, a minimum node dose of 5000 rad appeared to be sufficient for control, whereas for nodes greater than 6 cm, at least 6000 rad appeared to be required for optimal control. Fixed nodes required a higher dose compared to mobile masses. The incidence of postoperative complications was increased with maximum subcutaneous doses of greater than or equal to 6000 rad. There was also an increased incidence of postoperative complications for patients undergoing simultaneous, as compared with staged, bilateral neck dissection.     

The role of neck dissection in the combined modality therapy setting

No method reliably detects residual low-volume nodal disease in a patient with a complete response (CR) to treatment. Control of the N0-1 neck is to be expected after CR; no treatment is needed. Positron emission tomography (PET) may improve patient selection, but neck dissection should still be performed for patients with good performance status and residual masses. Neck dissection reduces the incidence of regional recurrence, although the impact on survival is small. Whether the risk of tumor recurrence or the morbidity of neck dissection should be of greater concern for patients with N2-3 disease in CR is a matter of individual judgment. Combined modality therapy will control most nodal metastases (even for patients with advanced nodal disease). Neck dissection in patients presenting with bulky nodal disease who achieve a CR after combined modality therapy will diminish the regional recurrence rate by about 15%. Nowadays, patients with N3 disease and CR often still have residual neck tumor. Node dissection is to be advised. Neck dissection should still be considered an important treatment modality for patients who undergo combined modality therapy with advanced nodal disease, even if they have achieved a CR.     

分区性颈清扫术应用在cN0和cN1期口腔癌中的远期效果

目的头颈部鳞状细胞癌的颈淋巴结的处理与预后密切相关,本文探讨了分区性颈清扫术应用于早期口腔鳞状细胞癌颈部转移的远期效果。方法84例cN0或cN1期患者均接受了术前化疗,分区性颈清扫术及术后放疗,并复习文献对比多种术式的颈部复发率。结果84例中1例死于肿瘤复发转移,53例cN1中有10例为pN0,全组颈部复发率为13＋2％。cN0中有6例出现隐性转移,该组复发率为6．5％。按是否侵犯包膜外颈部复发率分别是20．0％和10．3％。结论分区性颈清扫术在cN0和cN1期口腔鳞状细胞癌的治疗上可以取代改良性颈清扫和全颈清扫术。     

The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck

BACKGROUND: Sentinel lymph node (SLN) biopsy originally was described as a means of identifying lymph node metastases in malignant melanoma and breast carcinoma. The use of SLN biopsy in patients with oral and oropharyngeal squamous cell carcinoma and clinically N0 necks was investigated to determine whether the pathology of the SLN reflected that of the neck. METHODS: Patients undergoing elective neck dissections for head and neck squamous cell carcinoma accessible to injection were enrolled into our study. Sentinel lymph node biopsy was performed after blue dye and radiocolloid injection. Preoperative lymphoscintigraphy and the perioperative use of a gamma probe identified radioactive SLNs; visualization of blue stained lymphatics identified blue SLNs. A neck dissection completed the surgical procedure, and the pathology of the SLN was compared with that of the remaining neck dissection. RESULTS: Sentinel lymph node biopsy was performed on 40 cases with clinically N0 necks. Twenty were pathologically clear of tumor and 20 contained subclinical metastases. SLNs were found in 17 necks with pathologic disease and contained metastases in 16. The sentinel lymph node was the only lymph node containing tumor in 12 of 16. CONCLUSIONS: The SLN, in head and neck carcinomas accessible to injection without anesthesia, is an accurate reflector of the status of the regional lymph nodes, when found in patients with early tumors. Sentinel lymph nodes may be found in clinically unpredictable sites, and SLN biopsy may aid in identifying the clinically N0 patient with early lymph node disease. If SLNs cannot be located in the neck, an elective lymph node dissection should be considered.     

Multimodality therapy for unresectable squamous cell carcinoma of the head and neck

Eighteen patients with unresectable Stage III or IV squamous cell carcinoma of the head and neck were treated with induction therapy consisting of sequential methotrexate and 5-fluorouracil. This was followed by full course radiation therapy and radical neck dissection for those with residual neck disease. Those with local control were then treated with vinblastine, bleomycin, and cisplatin (VBP). Although 79% of patients achieved a partial or complete response to chemotherapy, only 50% of patients achieved local control. Marked mucositis limited the dose and schedule of radiation therapy. The methotrexate and 5-fluorouracil combination appears to be too toxic for multimodality therapy of advanced head and neck cancer.     

The role of interstitial brachytherapy with salvage surgery for the management of recurrent head and neck cancers

BACKGROUND: The role of interstitial brachytherapy (IBT) in the salvage surgical management of regional lymphatic metastases for head and neck cancer has not been defined to date. To further explore its therapeutic benefit in the management of head and neck squamous cell carcinoma, the authors reviewed their experience utilizing IBT at the M. D. Anderson Cancer Center. METHODS: A retrospective chart review of all patients who were received IBT for cervical recurrences of head and neck cancer was undertaken. Twenty-two patients were identified; all patients underwent neck dissection and intraoperative placement of afterloading catheters as part of the salvage treatment. Soft tissue reconstruction was performed when necessary. The duration and dosage of salvage brachytherapy was reviewed, and the overall disease-free survival rates were determined. RESULTS: All patients had been treated with external beam radiation therapy prior to recurrence, with an average dose of 65 grays (Gy), and 46% of patients had undergone prior neck dissection. The median time to regional recurrence after definitive treatment was 30 months. Soft tissue coverage of the surgical bed with a muscle flap, most commonly a pectoralis major flap, was performed in 19 of 22 patients. The median IBT dose was 60 Gy over a total duration of 4 days. Postoperative complications were few, and there were no perioperative deaths. Recurrences in the reirradiated necks occurred in 27% of patients. CONCLUSIONS: Regional recurrences are common after multimodality treatment for head and neck cancer and are challenging to manage. Although its role has not been defined clearly, salvage neck dissection with IBT is beneficial in the management of recurrent lymphatic metastases of upper aerodigestive tract carcinomas.     

An immunologic basis for detection of occult primary malignancies of the head and neck.

After extensive evaluation of patients with metastatic neck disease and clinically undetectable primary cancer of the head and neck, the clinician is often faced with the difficult question of subsequent management. In this study, sera from 11 patients with clinically occult carcinoma and metastatic lymphadenopathy were studied for Epstein-Barr virus-associated antigens. These were compared with 35 sera from patients with known nasopharyngeal carcinoma at all stages of disease and treatment and with 212 sera from control patients with other head and neck tumors, patients with lymphoma, and normal controls. There was a significant correlation between high antibody titers to Epstein-Barr virus, especially in the serum IgA fraction, and the presence of nasopharyngeal carcinoma. Thus, identification of occult nasopharyngeal carcinoma by immunologic means may have important application in the selective management of the patient with an unknown head and neck primary malignancy.     

Variations of the Cervical Internal Carotid Artery

The objective of this study was to report the variations of the cervical internal carotid artery, as encountered during neck dissection for head and neck malignancies. A retrospective analysis of neck dissections performed for the management of various head and neck cancers, during 2006–2010 was carried out. Among 102 patients and 119 neck dissections, five of them were found to be having abnormalities of the cervical part of the internal carotid artery during its course in the neck and were analyzed in detail. Out of five subjects, four were males and the other was female with age ranging from 50 to 74 years. Of the five patients two had mild degree of tortuosity, two patients had moderate degree of tortuosity and another patient had severe degree of tortuosity in the course of internal carotid artery in the neck. Based on our cases, the possibilities of various vascular variations should be kept in mind while performing the neck dissection. This will help in preventing inadvertent injury to these vital structures and prevents subsequent consequences.     

Significance of ferritin as a marker in head and neck malignancies

The efficiency of the combination of two tumor-associated antigens in recognising head and neck cancer was evaluated. The markers studied were CEA and ferritin by radioimmunoassay. CEA was estimated in 22 controls and 41 head and neck cancer patients. There was no difference in CEA values of controls and head and neck cancer patients, suggesting that CEA was not specific for head and neck malignancies. We measured serum ferritin in 27 controls and 58 patients with head and neck cancer. The mean ferritin level was significantly higher in patients (P less than 0.001) than in normal subjects. The ferritin level in patients with no evidence of clinical disease 8 months after treatment showed approximately normal levels, whereas the levels showed a tendency to increase or remain at high levels in patients with a poor prognosis, giving support to the contention that ferritin may prove to be a valuable adjunct in head and neck cancer.