ear, nose, and throat disorders
Overview of Head and Neck Tumors
Treatment of Head and Neck Tumors
Surgery, radiation therapy, or both Sometimes chemotherapy The main treatments for head and neck cancer are Surgery for Cancer and However, at certain locations, there is clear superiority of one modality. For example, surgery is better for early-stage disease involving the oral cavity because radiation therapy has the potential to cause mandibular osteoradionecrosis. Endoscopic surgery has become more frequently used; in select head and neck cancers, it has cure rates similar to or better than those of open surgery or radiation, and its morbidity is significantly less. Endoscopic approaches are most often used for laryngeal surgery and usually use a laser to make the cuts. Endoscopic approaches also are being used in the treatment of selected sinonasal tumors. If radiation therapy is chosen for primary therapy, it is delivered to the primary site and sometimes bilaterally to the cervical lymph nodes. The treatment of lymphatics, whether by radiation or surgery, is determined by the primary site, histologic criteria, and risk of nodal disease. Early-stage lesions often do not require treatment of the lymph nodes, whereas more advanced lesions do. Head and neck sites rich in lymphatics (eg, oropharynx, supraglottis) usually require lymph node radiation regardless of tumor stage, whereas sites with fewer lymphatics (eg, larynx) usually do not require lymphatic radiation for early-stage disease. Intensity-modulated radiation therapy (IMRT) delivers radiation to a very specific area, potentially reducing adverse effects without compromising tumor control. Advanced-stage disease (stages III and IV) often requires multimodality treatment, incorporating some combination of chemotherapy, radiation therapy, and surgery. Bone or cartilage invasion requires surgical resection of the primary site and usually regional lymph nodes because of the high risk of nodal spread. If the primary site is treated surgically, then postoperative radiation to the cervical lymph nodes is delivered if there are high-risk features, such as multiple lymph nodes with cancer or extracapsular extension. Postoperative radiation usually is preferred over preoperative radiation because radiated tissues heal poorly. Recent studies have shown that adding chemotherapy to adjuvant radiation therapy to the neck improves regional control of the cancer and improves survival. However, this approach causes significant adverse effects, such as increased dysphagia and bone marrow suppression, so the decision to add chemotherapy should be carefully considered. Advanced squamous cell carcinoma without bony invasion often is treated with concomitant chemotherapy and radiation therapy. Although advocated as organ-sparing, combining chemotherapy with radiation therapy doubles the rate of acute toxicities, particularly severe dysphagia. Radiation may be used alone for debilitated patients with advanced disease who cannot tolerate the sequelae of chemotherapy and are too high a risk for general anesthesia. Chemotherapy is almost never used as primary treatment for cure. Primary chemotherapy is reserved for chemosensitive tumors, such as Burkitt Lymphoma , or for patients who have widespread metastases (eg, hepatic or pulmonary involvement). Several drugs— Because the treatment of head and neck cancer is so complex, multidisciplinary treatment planning is essential. Ideally, each patient should be discussed by a tumor board consisting of members of all treating disciplines, along with radiologists and pathologists, so that a consensus can be reached on the best treatment. Once treatment has been determined, it is best coordinated by a team that includes ear, nose, and throat and reconstructive surgeons, radiation and medical oncologists, speech and language pathologists, dentists, and nutritionists. Plastic and reconstructive surgeons play an increasingly important role because the use of free-tissue transfer flaps has allowed functional and cosmetic reconstruction of defects to significantly improve a patient's quality of life after procedures that previously caused excessive morbidity have been done. Common donor sites used for reconstruction include the fibula (often used to reconstruct the mandible), the radial forearm (commonly used for the tongue and floor of mouth), and the anterior lateral thigh (often used for laryngeal or pharyngeal reconstruction). Managing recurrent tumors after therapy is complex and has potential complications. A palpable mass or ulcerated lesion with edema or pain at the primary site after therapy strongly suggests a persistent tumor. Such patients require CT (with thin cuts) or MRI. For local recurrence after surgical treatment, all scar planes and reconstructive flaps are excised along with residual cancer. Radiation therapy, chemotherapy, or both may be done but have limited effectiveness. Patients with recurrence after radiation therapy are best treated with surgery. However, some patients may benefit from additional radiation treatments, but this approach has a high risk of adverse effects and should be done with care. The Immunotherapy and Targeting Inhibitors of Immune Responses Pain is a common symptom in patients with head and neck cancer and must be adequately addressed. Palliative surgery or radiation may temporarily alleviate pain, and in 30 to 50% of patients, chemotherapy can produce improvement that lasts a mean of 3 months. A stepwise approach to pain management, as recommended by theWorld Health Organization: Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents, is critical to controlling pain. Severe pain is best managed in association with a pain and palliative care specialist. Pain, difficulty eating, choking on secretions, and other problems make adequate symptomatic treatment essential. Patient Advance Directives regarding such care should be clarified early. All cancer treatments have potential complications and expected sequelae. Because many treatments have similar cure rates, the choice of modality is based largely on real, or perceived, differences in sequelae. Although it is commonly thought that surgery causes the most morbidity, many procedures can be done without significantly impairing appearance or function. Increasingly complex reconstructive procedures and techniques, including prostheses, grafts, regional pedicle flaps, and complex free flaps, can restore function and appearance often to near normal. Toxic effects of chemotherapy include malaise, severe nausea and vomiting, mucositis, transient hair loss, gastroenteritis, hematopoietic and immune suppression, and infection. Therapeutic radiation for head and neck cancers has several adverse effects. The function of any salivary gland within the beam is permanently destroyed by a dose of about 40 Gray, resulting in Xerostomia , which markedly increases the risk of dental caries. Newer radiation techniques, such as intensity-modulated radiation therapy (IMRT), can minimize or eliminate toxic doses to the parotid glands in certain patients. 60 Gray, and osteoradionecrosis may occur (see also Radiation therapy ). In this condition, tooth extraction sites break down, sloughing bone and soft tissue. Therefore, any needed dental treatment, including scaling, fillings, and extractions, should be done before radiation therapy. Any teeth in poor condition that cannot be rehabilitated should be extracted. It is unclear whether Radiation therapy may also cause oral mucositis and dermatitis in the overlying skin, which may result in dermal fibrosis. Loss of taste (ageusia) and impaired smell (dysosmia) often occur but are usually transient. 