American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Volume 27, Issue 2 , Pages 73-75, March 2006

The head and neck surgeon as oncologist

Department of Surgical Sciences, ENT Clinic, University of Udine, Udine, Italy

Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA

Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

Article Outline

 

During the second half of the past century, sophisticated techniques for surgical management of head and neck cancer evolved, using the concepts of block resection of primary tumor in continuity with the nodal metastatic basin, along with techniques for effective reconstruction of the surgical defect. At the same time, the methodology, instrumentation, and precision of treatment of head and neck cancer with ionizing radiation and the development of effective chemotherapeutic agents for adjuvant or neoadjuvant therapy for these tumors developed in stride with the surgical achievements. In the early decades of this period, patients were treated initially with irradiation or surgery, often depending on which specialist they happened to consult first. Treatment with the other modality was often reserved for failure of the first. This often led to ultimate failure and high morbidity, particularly when treatment was attempted for the more advanced tumors. By the latter decades of the century, it became evident that optimal treatment of head and neck cancer could best be achieved by planned multimodality treatment, with pretreatment evaluation by a multidisciplinary group consisting of surgeons, radiation oncologists, and medical oncologists, as well as radiologists, scintigraphers, pathologists, and dental, rehabilitative, and palliative care specialists. Thus, most cancer institutions have developed “Tumor Boards,” which systematically evaluate, plan, and follow treatment for patients with head and neck cancer, and develop a consensus for management. An important consideration in such decision making relates to the posttreatment quality of life [1], [2].

Such multidisciplinary groups present their own problems. Decisions cannot be reached by simple majority vote. The surgeon, often the first one to have seen the patient, must be well versed in the availability, efficacy, and morbidity of various nonsurgical treatment modalities and protocols, and must be prepared to lead the discussion and be the arbiter of decision making.

Cancer of the head and neck accounts for less than 10% of all malignant tumors. More than 500000 new cases of head and neck cancers are projected annually worldwide, and this incidence is rising. There are approximately 50 different anatomic sites and subsites in the head and neck [3] and several successful treatment alternatives in the management of head and neck cancer. About 90% of head and neck cancers are squamous cell carcinoma, which arises from the surface epithelium. Many other oncotypes may be present in this area [4], [5]. Approximately one third of the patients present with early-stage disease (stages I and II), whereas the remaining patients present with advanced disease (stages III and IV) [6]. Often, patients with early-stage disease are treated with single-modality therapy with curative intent, whereas multimodality protocols are used for more advanced stages. Treatment may be influenced by the availability of certain modalities or expertise in various parts of the world.

Numerous factors and advances have helped develop new paradigms in treatment of head and neck cancer. All patients with head and neck cancers cannot be considered as having the same neoplastic disease. Treatment and prognosis depend on several factors, but the histologic status of cervical lymph nodes is the most independent prognostic variable for recurrence and survival in patients with squamous cell carcinoma of the head and neck. Molecular markers may assist us as new prognostic indicators [7]. The surgeon should consider the probability of occult micro- and nonmicrometastases. Selective neck dissections, in which only the node levels at greatest risk for metastases are removed, are most useful not only as staging procedures for detection of the presence of metastatic disease, but also as therapeutic dissections in early and selected advanced-stage lesions. These neck dissections, with reduced morbidity and superior cosmetic and functional results, have greatly eased the previous dilemma concerning “elective” neck dissection, and can also permit effective single-modality therapy in patients with nodal disease limited to the areas resected. Selective neck dissection is thus indicated in N0 patients and in selected patients with N+ disease [8], [9]. There is also a role for selective neck dissection after chemoradiation for head and neck cancer [10]. Thus, one of the new paradigms in the management of patients with advanced head and neck cancer is that “less may mean more” [11].

Radical and modified radical neck dissection will continue to be indicated and used, but these 2 comprehensive neck dissections, which include all 5 levels of lymph nodes as well as the sacrifice of various nonlymphatic structures in the more radical procedures, should only be used when indicated by extensive disease. The surgeon should consider that more extensive neck dissection does not equate to more curative treatment. “Heroic” attempts at surgical resection of extensive neck disease should be tempered by an understanding of the high incidence of ultimate distant metastasis in such cases, as well as the generally poor quality of life during the brief disease-free interval that may be expected [12].

Other surgical and nonsurgical approaches during the past 2 decades have produced a major paradigm shift in the management of early and advanced head and neck cancer because of advances in technology, molecular biology, immunohistochemistry, and better understanding of the biology of head and neck cancer. In addition to a more conservative approach to neck disease, new surgical techniques that comprise a less invasive approach to treatment of early or relatively early-stage primary cancer include conservative laryngeal surgery, performed transorally with the laser or externally by partial or supracricoid laryngectomy. The techniques of endoscopic sinus surgery can be used for both benign and malignant tumors. Other techniques permit a less invasive approach to tumors of the oral cavity and pharynx. On the other hand, the development of musculocutaneous and revascularized free flaps [13], [14] have greatly enhanced the ability of the surgeon to deal with more extensive problems involving resections of mandible, significant portions of the oral cavity and pharynx and pharyngoesophageal reconstruction. Massive necrosis of skin flaps, major fistula formation, and carotid artery rupture—frequent sequelae of past attempts to treat advanced-stage head and neck cancer—rarely occur in current surgical practice mostly because of these improvements in reconstructive surgery. The need for such reconstruction requires additional members of the team, whose skills must be coordinated by the head and neck surgeon, as oncologist.

Management of advanced head and neck cancer requires involvement of all disciplines to optimize treatment for utmost oncologic control of the tumor and better quality of life. In this respect, chemotherapy and irradiation, used separately or in combination with each other or with surgery, have greatly increased our ability to achieve these goals. Realization of the synergistic effect of combined chemotherapic and radiation modalities has produced a breakthrough in treatment [15]. In addition, although platinum-based chemotherapy is still the mainstay of most regimens, new agents and approaches have been constantly investigated, including antiangiogenesis factors, immunotherapy, and gene therapy. Radiation therapy approaches have evolved enormously in recent years with advances in fractionation including hyperfractionated treatment, 3-dimensional accurate simulation, and targeting of high-dose radiation therapy, intensity-modulated radiation therapy, and various forms of brachytherapy. Radiation has been used as primary or adjuvant treatment modality for head and neck recurrences or second primary tumors in previously irradiated areas [16].

Another aspect of head and neck oncology concerns the prevention of disease, either initially, or as second primary cancers. The high incidence of second primary tumors has been unmasked by the efficacy of treatment of the initial cancer. Smoking and alcohol abuse are well-known etiologic factors in both initial and subsequent head and neck cancers. Heavy smokers and drinkers are at a higher risk of presenting with advanced tumor [17]. Cessation has produced an enormous impact in reducing the high incidence of second primary tumors in patients with head and neck cancer, and it is up to the surgeon, as oncologist, to emphasize this fact to patients as well as to help them seek appropriate counseling to make the necessary lifestyle changes. Other etiologic factors may also be of importance. In recent years, there appears to be a higher incidence of head and neck cancer development in younger individuals [18], both nonsmokers and nondrinkers [19]. Whether the biology of these tumors is different and whether their behavior is different from usual head and neck cancer remain to be studied.

Thus, today's head and neck surgeon should be an oncologist, in the fullest meaning of the term, who is able to coordinate a multidisciplinary team approach, in addition to possessing technical expertise in head and neck surgery. A rational treatment plan can be formulated based upon consideration of tumor-intrinsic factors, patient factors, multidisciplinary team expertise, and available technical resources (Table 1).

Table 1. Treatment plan requires a diligent evaluation of the following factors
Tumor intrinsic factorsPatient-related factorsMultidisciplinary team expertiseAvailable technical resources
SiteCancer-related symptoms and signsHead and neck surgeon (and plastic and reconstructive surgeon, neurosurgeon, oral, and dental surgeon)Monitor
ExtentMorbidity (multiple primary tumors)Radiation oncologist (IMRT)Anesthesia
Pathological characteristicsMedical comorbidityMedical oncologistHead and neck intensive care unit
Biomarkers Speech therapistRehabilitation
Depth of tumor PhysiotherapistFollow-up
Margin status Nurse specialist
Nodal status
Extranodal disease

IMRT, intensity-modulated radiation therapy.

The surgeon should demonstrate sensitivity to cultural competence, education, research, and technological advancements. Training should not be confused with education [20].

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References 

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PII: S0196-0709(05)00151-1

doi:10.1016/j.amjoto.2005.07.022

American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Volume 27, Issue 2 , Pages 73-75, March 2006

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