Recent advances in reconstructive surgery: head and neck reconstruction

Although advances in radiotherapy and chemotherapy for cancers of the head and neck have been remarkable, surgical resection followed by reconstructive surgery is still the mainstay of treatment. Of the reconstructive procedures, microsurgical tissue transfer has been considered the standard method for restoring postoperative functions and morphology. In this review article, we discuss the history of reconstructive surgery for treating cancers of the head and neck, current problems, and future challenges.     

Reconstructive surgery in head and neck cancer

In the past 15 years dynamic changes have taken place in primary reconstructive procedures for head and neck cancer. We have here described the latest techniques used at the Tata Memorial Hospital in reconstruction of major defects in head and neck cancer surgery.     

Chemotherapy advances in locally advanced head and neck cancer

The management of locally advanced unresectable head and neck squamous cell cancer (HNSCC) continues to improve. One of the major advances in the treatment of HNSCC was the addition of chemotherapy to radiation in the treatment of non-surgical patients. The majority of the data regarding chemotherapy in HNSCC involve cisplatin chemotherapy with concurrent radiation. However, several new approaches have included targeted therapy against epidermal growth factor receptor and several recent studies have explored the role of induction chemotherapy in the treatment of HNSCC. The purpose of this article is to provide an overview of the role of chemotherapy in the treatment of locally advanced HNSCC.     

Recent advances in epidemiology of head and neck cancer.

Cancer of the oral cavity is an important contributor to the overall international cancer burden, especially in the developing countries. Smoking cessation, moderation of alcohol consumption, and increased consumption of fruits, and probably vegetables, have been identified by epidemiologic studies as three actions that could lead to the prevention of approximately three fourths of cases in Western countries. Similar effects could be brought about in developing countries through cessation of cigarette smoking and, where appropriate, betel quid chewing and increased consumption of fruits and vegetables. Since this disease is increasing in frequency in many countries, it is important to implement these health education messages. A similar situation holds true for larynx cancer. Clearly many head and neck cancers are preventable and it is worth repeating that prevention should become an epidemiologic priority. There are exciting prospects of effective chemoprevention opportunities in head and neck cancer, with a number of compounds having activity. Further developments in this important area are awaited.     

Recent advances in molecular-targeted drugs in head and neck cancer

Recently, the integration of radiotherapy and chemotherapy has advanced the treatment of locally advanced squamous cell carcinoma of the head and neck (SCCHN), allowing functional organ preservation while improving locoregional control and overall survival compared with radiotherapy alone. However, as recurrences remain inevitable, there is an absolute need for alternative modes of therapeutic intervention. Moreover, the use of chemotherapy and radiotherapy also increases the incidence of toxicities such as mucositis, myelosuppression, xerostomia, and dysphasia. More recently, the use of molecular-targeted drugs, which minimally adds to the existing toxicities, along with cytotoxic drugs and radiotherapy has been intensively investigated. Cetuximab is a chimeric IgG1 monoclonal antibody that specifically blocks the epidermal growth factor receptor. In a randomized trial of radiotherapy with or without cetuximab for locally advanced SCCHN, the addition of cetuximab significantly improved the locoregional control and overall survival without an increase in adverse events. Furthermore, a randomized trial of 5-FU and cisplatin with or without cetuximab for recurrent/metastatic SCCHN demonstrated a significant survival benefit for cetuximab combination arms compared with 5-FU and cisplatin arms alone. Based on these findings, many molecular-targeted drugs have been investigated in the treatment of the head and neck cancer to ensure better clinical outcomes in the near future.     

Surgical reconstruction in patients with cancer of the head and neck

Reconstructive surgical techniques have greatly changed the treatment approach for patients with cancer of the head and neck. These techniques provide head and neck surgeons the flexibility of performing tumor resection without concerns about the repair of the final defect and significantly increase the quality of life in patients who have undergone ablative surgery by providing better cosmetic and functional outcome after cancer resection. Reconstruction of the defects after ablative surgery for head and neck cancer includes various options, and each option has its own advantages and disadvantages. Techniques for head and neck reconstruction are summarized in this article along with recent advances in their application.     

Wound infection in head and neck cancer surgery

Wound infections (WIs) are the main cause of post-surgical morbidity in head and neck surgery. They arise with an especially immunocompromised predisposition and mainly involve oropharyngeal flora bacteria. However, the assessment of the incidence of these infections differs in the literature (0 to 87%). This in part accounts for the lack of a real consensus as to the definition (do all mucocutaneous fistulae attest to WIs?). For this reason, the analysis of their risk factors and the means of the prevention is difficult. In class 1 surgery, the incidence of WIs ranges 0 to 6%. In this case, antiobioprophylaxis does not seem to be justified. In surgery opening the mucosa, it is difficult to classify the surgical procedures in Altemeier's classes 2 and 3. There are many arguments, in particular physiopathological arguments, to consider that the contamination of surgical bed of surgery does continue after the operation. The incidence of WIs varies widely from one study to the next. Without antibiotic prophylaxis, from 40 to 87% WIs are observed. With preventive antibiotherapy, the incidence ranges between 3.4 to 47%. Various risk factors have been described, in particular: tumour size and node extension, tracheotomy prior to surgery. Four multi-factor studies have shown, in multivariate analysis, totally different risk factors. The prevention of these WIs is currently based on hospital hygiene rules and antibiotic prophylaxis. The optimum conditions have still not been determined. Reliable data to define, the incidence and risk factors of these WIs are missing. New prospective studies are definitely required.     

Recent advances in radiation therapy for head and neck cancer

The most efficacious treatment method for head and neck cancer is not yet defined. However, there have been some improvements made in the radiotherapy of head and neck cancer that are encouraging. Both hyperfractionated radiation therapy and accelerated radiation therapy have improved the local control rates in numerous primary sites, and the results of more rigorous prospective randomized studies, if positive, will justify more routine use of these techniques. The use of neutrons for unresectable salivary gland tumors has clearly been established as the treatment of choice. Local control as well as cosmetic outcome is excellent, with the only disadvantage being that neutron therapy is not as widely used as photon radiation. The same is true for charged particle therapy, the greatest utility of which appears to be for relatively small tumors adjacent to critical structures such as the brain and spinal cord. We also believe that intraoperative radiation therapy shows great promise and may soon be more widely available for the treatment of head and neck cancers. However, we believe that the most exciting advancement in the treatment of head and neck cancer is the use of concomitant radiation therapy and chemotherapy, a topic that is discussed in detail in another article in this issue.     

Current status of biomarkers in head and neck cancer

As our understanding of HNSCC increases so has biomarker development. HPV16 integration is a significant marker of favorable prognosis and response to therapy for HNSCC. EGFR-amplification and overexpression is a poor-prognostic indicator. For premalignant lesions, LOH of 3p&9p21 loci confers an elevated risk of malignant transformation. As molecular targets are identified, these will be candidates for biomarkers for detection, diagnosis, prognosis, and therapy. Validation of these biomarkers requires demonstration of independence of significance beyond known biomarkers.     

Current status of FDG-PET for head and neck cancer

18-FDG-PET has utility for the identification of the unknown primary head and neck squamous carcinoma, distant metastases or second primary carcinomas, and recurrent HNSCC in the post-treatment setting. PET has a high negative predictive value in the detection of recurrent HNSCC. Standardized uptake values have demonstrated prognostic value. Limitations of PET include a lower utility for identifying occult nodal metastases and false positive readings from inflammation, infection, muscle activity, and radiation effect. Novel radioactive tracers may enable PET to identify sites of DNA replication, protein metabolism, and hypoxia.     

Current role of gene therapy in head and neck cancer.

Our increasing knowledge of cancer molecular biology has led to the development of new genetic therapies for the treatment of cancer. Such therapies are advantageous in that they can selectively target tumour tissue leaving normal tissue relatively unaffected. In squamous cell cancer of the head and neck, such therapies may be beneficial in the treatment of loco-regional recurrence, minimal residual disease and in the treatment of distant metastatic disease. This article describes the principles of cancer gene therapy reviews some early clinical trials of gene therapy in head and neck cancer.     

头颈部黏膜恶性黑色素瘤的临床诊治现状及进展

头颈部黏膜恶性黑色素瘤是一类少见的恶性肿瘤,主要发生在鼻窦和口腔,5年生存率不到30%。目前治疗模式尚存争议。多数回顾性研究结果显示术后放疗可以提高LC,但OS率未见明显获益。本文旨在加强对头颈部黏膜恶性黑色素瘤的认识,包括其临床特点、诊断、分期、治疗模式和疗效等。