HEAD AND NECK CANCER: ADVICE ON MANAGEMENT
From Current Concepts in Head and Neck Surgery, presented by Memorial Sloan-Kettering Cancer Center and
University of Texas M.D. Anderson Cancer Center
| CANCER OF THE ORAL CAVITY: CHEMOPREVENTION —Jay Boyle, MD, Assistant Attending Surgeon, Head and
Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY
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| Squamous cell carcinoma of oral cavity: risk for cancer increases ≈40-fold in individuals who smoke tobacco and
drink alcohol; field carcinogenesis—creates environment favoring carcinogenesis; concept based on abnormal, heterogeneous
clonal populations located throughout upper aerodigestive tract (can contain genetic changes critical to carcinogenesis)
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| Leukoplakia: one third of—oral cancers arise within area of known leukoplakia; dysplastic leukoplakia progresses to
cancer; differential diagnosis—Candidiasis; lichen planus; frictional lesions; HIV-related problems; leukoplakia associated
with tobacco use—can develop on lip, tongue, floor of mouth; palatal hyperkeratosis not uncommon; chewing
tobacco often leads to hypertrophic areas (less likely to be precancerous than smoking-related leukoplakia); idiopathic
leukoplakia—can become cancerous in nonsmokers
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| Natural history: dysplasia—associated with relatively low rate of progression (30%); found in ≈15% of white patches;
occurs most often on tongue, floor of mouth, and lip; data suggest—monitoring reasonable in patients who are reliable
and willing be observed; patient with small resectable lesion may benefit from excision; biopsy of white patch—
perform at least once in patient to be observed or treated; helps assess conversion risk and identify tissue to excise; sample
with punch biopsy to determine whether medium-sized lesion benign
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| Lesions: erythroplakia—reddish or speckled lesions more likely to be high-grade disease requiring aggressive treatment;
nonhomogeneous, dysplastic lesions at increased risk for transformation to carcinoma if present—for long
time; in women or nonsmokers; on floor of mouth or on tongue
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| Progression risk: degree of dysplasia poor predictor of specific individual’s risk for progression; markers—patients
with polysomy 9, p53 expression, and loss of heterozygosity for 3p or 9p at high risk for progression; value limited by
lack of availability; toluidine blue stain may help detect molecular changes; DNA aneuploidy—measured by image cytometry;
may predict progression to oral cancer; data suggest if dysplastic leukoplakia—diploid, progression rare; tetraploid,
progression risk intermediate; aneuploid, risk for progression and death high; grading of histology (mild,
moderate, or severe) poor predictor of progression
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| Management: morbidity from oral surgery—generally moderate; severe after multiple mucosal excisions of tongue
and value to patients marginal; monitoring protocol—based on low risk for recurrence over 10 yr; evaluates patient 2 to
3 times yearly for 10 yr; favored by many patients who have undergone multiple operations; if cancer develops, cure rate
excellent (90%-95% with resection); patients with—benign, hyperkeratotic lesion (progression risk low; observation
appropriate; remove small lesions); mild dysplasia and small lesion, at least 1 attempt at resection reasonable; high-grade
lesions require excision; large mild dysplasia covering ventrum of tongue should be observed
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| Treatment: standard excision of mucosal tissue provides pathology specimen; (CO2 laser ablation does not provide significantly
better functional outcome); medical therapy—oral vitamin A (13 cis-retinoic acid; ineffective; toxicity moderate;
not recommended for prevention of second primaries); topical vitamin A can shrink verrucous lesion (helpful for
patient with multiple or diffuse lesions); cyclooxygenase-2 (COX-2) inhibition, eg, celecoxib (Celebrex), potential preventive
option
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| MANAGING EARLY CANCER OF THE LARYNX —Snehal G. Patel, MD, Assistant Attending Surgeon, Head and
Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY
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| Early cancer of larynx: stage T1 and T2 squamous cell carcinoma with clinically and radiologically negative neck
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| Work-up of suspicious lesion: history and physical examination; assess anatomic “blank spots” within larynx, ie, infrahyoid
epiglottis, anterior commissure, and supraglottic larynx (topical anesthesia facilitates examination); document
with still and video images; points—avoid punch biopsy of small lesion (makes subsequent assessment and treatment of
residual tumor difficult); obtain imaging studies before surgery; assess patient under anesthesia if clinical examination inadequate;
radiographic assessment of early glottic cancer not cost-effective; imaging for supraglottic cancer—helpful
because disease prone to lymphatic spread; should assess pre-epiglottic space; computed tomography (CT) first-line option;
magnetic resonance imaging (MRI) susceptible to motion artifacts from swallowing, but can help assess pre-epiglottic
space
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| Management: single modality, ie, surgery or radiation achieves satisfactory results; chemotherapy not primary treatment
in United States; surgical options for—supraglottic cancer include conventional horizontal partial or supraglottic laryngectomy;
glottic cancer (open operations range from laryngofissure and cordectomy to vertical partial and supracricoid
laryngectomy; endoscopic procedures can be tailored to limited local excision or full-fledged partial laryngectomy); N0
neck—concern with supraglottic cancers (incidence of occult lymph nodes justifies surgery); early glottic cancers do not
involve neck; neck levels II through IV at highest risk; consider bilateral neck dissection when lesion near to or involves
midline or base of tongue
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| Treatment selection: best treatment may not be most appropriate for specific patient; factors to consider—disease
control; laryngeal function; tumor characteristics; patient survival and overall quality of life; cost, duration, and toxicity
of treatment; whether treatment can be repeated; physician and institutional preferences; level of training and expertise of
physician
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| Patient evaluation includes: medical comorbidity; lifestyle-related issues; occupation; body habitus
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| Comparison of treatment options
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 | Early supraglottic cancers: surgery slightly better than radiation for overall survival and local control; postoperative functional
results focus on aspiration and pneumonia; when compared to endoscopic laser resection, patients undergoing
horizontal supraglottic partial laryngectomy—have more severe functional derangement and higher incidence
of aspiration and pneumonia; require temporary tracheotomy; may need long-term enteral feeding; more likely to require
salvage total laryngectomy to manage aspiration
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| Early glottic cancers: among patients with—T1 lesions, survival and local control equivalent for radiation therapy, open
surgery, and endoscopic resection; T2 lesions, open surgery achieved better local control than endoscopic resection or
radiation therapy; functional results—open surgery inferior to endoscopic resection and radiation therapy; voice
quality—frequently weak and breathy after partial laryngectomy; in carefully selected patients, results potentially comparable
for endoscopic laser resection and radiation therapy
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| Anterior commissure: extends ≈1 cm in craniocaudad direction (difficult to access with endoscopic procedure or external
beam radiation); adjacent thyroid cartilage—devoid of perichondrium; at high risk for invasion if tumor extends
≥1 cm below level of commissure; bilateral involvement restricted to level of glottis does not increase risk; caveats—risk
for spread mandates endoscopic examination of tumors extending into commissure; involvement of anterior commissure
worsens local control rates after radiotherapy and endoscopic laser resection; open surgical resection of tumors involving
anterior commissure—achieves better local control rates and poorer voice quality; recommended for larger, infiltrative
lesions; radiotherapy techniques—probably equal efficacy of open surgery for limited exophytic lesions
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| Verrucous carcinoma: <1% of all head and neck cancers; involves glottis and larynx most often; presents early on;
etiology—associated with human papillomavirus (HPV) types 6 and 11; may be related to smoking tobacco; lesions—
densely keratinized with warty surface (use punch biopsy); benign; locally destructive; treated surgically in United
States; points—endoscopic laser resection appropriate for early lesions; modern radiation techniques probably equally
effective and do not produce anaplastic transformation; with early diagnosis and appropriate treatment, prognosis excellent
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| Radiation failure: local failure in 15% to 40% of early supraglottic and 15% to 25% of early glottic carcinomas; managed
with total laryngectomy; salvage supraglottic laryngectomy and vertical partial laryngectomy achieve acceptable
oncologic and functional outcomes and local control in selected patients; partial laryngectomy in selected patients—
permits total laryngectomy without compromising survival; provides acceptable functional outcome
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| MANAGING CANCER OF THE HYPOPHARYNX —Dr. Boyle
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| Hypopharyngeal cancer: uncommon; survival and post-treatment function poor; changes in paradigm for primary treatment
toward radiation-based therapy and organ preservation (chemoradiation adapted to expertise); poor survival related
to—advanced stage at presentation (lesions often silent and large at diagnosis); lymph node status (most patients present
with N+ disease; many patients with N0 disease have occult metastases); tendency toward bilateral spread associated with
rich submucosal blood supply; submucosal spread (3-cm inferior and 2-cm lateral surgical margins recommended); exposure
of hypopharynx to alcohol and/or tobacco; high incidence of second primaries in pharynx and esophagus and post-treatment
morbidity
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| Disease: more common among men in United States; squamous cell cancer constitutes 95% of lesions; tumors occur
most often in—piriform sinus, posterior cricoid area, and posterolateral wall; overlapping sites common; salivary gland
tumors—radioresistant; surgery generally recommended for lesions with salivary gland histology; patients—often
present with neck nodes and no symptoms in pharynx; can present with sore throat and dysphagia; referred otalgia important
sign of hypopharyngeal tumor; can develop hoarseness, weight loss, and odynophagia; at Memorial Sloan-Kettering,
majority present with stage III and IV disease; T4a and large T3 disease—require primary surgical management
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| Observations on staging: history and physical examination essential; fiberoptic laryngoscopy can detect tumors in
aryepiglottic (AE) fold or piriform sinus; elective neck dissection detected ≈50% rate of occult cervical metastases in patients
diagnosed with N0 disease; lymphatics of hypopharynx—profuse; tumors spread to jugular, paratracheal, tracheal,
esophageal, and retropharyngeal nodes; hypopharyngeal tumors typically—spread to levels II, III, and IV in
neck; usually do not metastasize to levels I or V unless lymph nodes already involved in other levels; prophylactic neck
dissection for N0 cases—can include levels II, III, IV, and lower part of V; does not address nodes in retropharyngeal
region, tracheoesophageal groove, or retroesophageal region (these node sets can be involved with papillary thyroid carcinoma;
consider these areas when planning surgery); imaging—MRI or CT provide cross-sectional imaging; chest X-
ray shows multiple pulmonary metastases; positron emission tomography (PET) helps detect bilateral neck metastases;
barium swallow helps delineate lower extent of lesion; fiberoptic esophagoscopy useful adjunct; additional aspects—
mapping biopsies determine tumor location; examination under anesthesia key aspect of staging; panendoscopy not cost-
effective; triple endoscopy detects synchronous tumors in esophagus and pharynx
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| Surgery: primary treatment modality; problems—patient refusal of laryngectomy; technical difficulty of primary and
salvage surgery; high incidence of distant metastases, contralateral neck recurrence, and mortality
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| Treatment: radiation therapy alone can treat large area of hypopharynx and bilateral N0 neck; surgical options for early
disease—partial pharyngectomy with bilateral neck dissection; partial laryngopharyngectomy; endoscopic resection
(limited value; consider for managing previously irradiated patients or second primaries in patients with laryngeal or
oropharyngeal tumors); options for advanced disease—total laryngectomy with partial or total pharyngectomy; neck
dissection with postoperative irradiation; chemoradiation—provides survival benefit for patients with multiple nodes,
extracapsular extension, perineural invasion, or positive margins; current approach—guided by laryngeal preservation;
includes chemoradiation with surgical salvage; effective but not universally available; when choosing treatment,
assess—tumor histology, site, and stage; need for laryngectomy; age and general condition of patient; previous treatment;
patient preference; availability of appropriate expertise; goals—control of cancer; one-stage reconstruction;
safety; restoration of alimentary continuity; maximizing quality of life
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| Management approaches: posterior pharyngeal wall tumors can be managed with traditional transhyoid approach (endoscopic
approach may be better option); tumor of piriform sinus can be managed with lateral pharyngeal approach; partial
laryngopharyngectomy—criteria for surgery (disease confined to upper hypopharynx; no involvement of apex;
mobile ipsilateral hemilarynx); contraindications (fixed vocal cord; damaged thyroid cartilage; involvement of piriform
apex; bilateral neck metastases; pulmonary insufficiency); points (swallowing difficult with insensate, immobile flap and
absence of large portion of supraglottic larynx; irradiation may improve disease-free survival; low-volume neck disease
and early stage favorable prognostic factors); total laryngectomy—required by most patients; options for postoperative
reconstruction—free jejunum preferred for reconstructing pharynx after total pharyngectomy; radial forearm patches
used after partial pharyngectomy; rectus muscle used after resection of large bulky lesions; chemoradiation of
hypopharynx—permits organ preservation; obtains wide margins; manages bilateral neck disease; good control and functional
outcome; among salvage patients—reanastomosis rendezvous procedure developed to manage post-treatment
pharyngeal strictures
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Educational Objectives
| The goal of this program is to educate the listener about current techniques for managing head and neck cancer. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Identify factors creating a predisposition for oral cavity cancer.
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| 2. Explore options for managing leukoplakia in patients at risk for oral cavity cancer.
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| 3. Diagnose and treat early cancer of the larynx.
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| 4. Evaluate and stage patients presenting with hypopharyngeal cancer.
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| 5. Select appropriate surgical management for hypopharyngeal cancer.
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Discussed on This Program
Celecoxib [Celebrex]
Sulindac [Clinoril]
Vitamin A [Aquasol A, Palmitate-A 5000]
Suggested Reading
Brown KS, Kane MA: Chemoprevention of squamous cell carcinoma of the oral cavity. Otolaryngol Clin North Am
39:349, 2006; Fan GK et al: Immunohistochemical analysis of P57(kip2), p53, and hsp60 expressions in premalignant
and malignant oral tissues. Oral Oncol 42:147, 2006; Gillenwater AM, Chambers MSD: Diagnosis of premalignant
lesions and early cancer of the oral cavity. Tex Dent J 123:512, 2006; Jones AS et al: The treatment of early laryngeal
cancers (T1-T2N0): surgery or irradiation? Head Neck 26:127, 2004; Lohynska R et al: Predictors of local failure
in early laryngeal cancer. Neoplasma 52:483, 2005; McLaughlin MP et al: Salvage surgery after radiotherapy failure
in T1-T2 squamous cell carcinoma of the glottic larynx. Head Neck 18:229, 1996; Ozer E et al: Intensification regimen
for advanced-stage resectable hypopharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 132:385, 2006; Spector
JG et al: Stage 1 (T1N0M0) squamous cell carcinoma of the laryngeal glottis: therapeutic results and voice preservation.
Head Neck 21:707, 1999; Watanabe A et al: Impact of endoscopic screening on early detection of hypopharyngeal
cancer. Head Neck 28:350, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Patel is affiliated with Elsevier Science.
Drs. Boyle and Patel gave their scientific presentations at Current Concepts in Head and Neck Surgery held November
12-13, 2005, in New York, NY, and cosponsored by the Memorial Sloan-Kettering Cancer Center and the University
of Texas M.D. Anderson Cancer Center. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
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