Head and Neck Cancers PART – 5 – Surgical management

HEAD & NECK CANCER PART-5

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)
Question: Dr. Chiragbhai, thank you for summarizing overall management plan for these cancers. So many subsites, and the fact that for anterior sites, surgery is preferred, but as you go posterior in head and neck region, surgical morbidity is much higher whereas radiation combined with chemotherapy can achieve same results with much better functional outcome. It was also surprising to know that radiation-chemotherapy combination has replaced surgery for larynx cancer for last two decades, and now for few other sites like hypopharynx and base of tongue in most cases.
Ans: However please do remember that patient evaluation should always include all three oncology specialties, at least two in most cases. Surgery has also evolved and good functional preservation is possible in some cases. Also, patients with advance disease, stage 3 high volume or stage 4 disease, frequently need surgery radiation and chemotherapy all three treatments in many cases.
Que: Before we go ahead, I have a simple question sent by one reader. A number of patients have concern that biopsy leads to faster growth of disease and risk of spread. Hence they want treatment without biopsy, such as operation based on CT scan which looks very obviously cancer like, or starting radiation/chemotherapy. Why do we need biopsy confirmation when CT or MRI is so obvious?
Ans: Thank you for asking this question, commonly asked by many patients. In fact, few patients continue to change doctors since they have so much fear of biopsy, and end up with very advance untreatable disease because of this waiting. THIS IS A MISCONCEPTION. TUMORS DO NOT SPREAD DUE TO BIOPSY. No center in the world treats these cancers without biopsy confirmation. There are no indirect tests, such as any type of scan, or blood test, that can confirm diagnosis of these cancers. Also, there are different types of cancer (different histologies), and cancers from other body sites may spread to head and neck region. Increasingly, we also need tissue for special tests, which help in planning treatment, hence it is better to preserve some tissue in special paraffin blocks (important when patient is undergoing radiation or chemotherapy as first treatment).
It is important for our readers to understand this MANDATORY need for biopsy, anywhere in the world, and hence properly reassure and counsel their patients.
Que: You also mentioned about “specialized head and neck cancer surgeon” in last discussion. What is the need, and are they available in India?
Ans: Head and Neck is a highly complex region, with so many critical structures, in and nearby this area. Surgery in this area can have very serious impact on:
1. Function: speech, swallowing, breathing (sometimes vision, blood calcium level) – only one or all 3 functions may be affected.
2. Cosmesis: surgery here can leave patient’s face so changed that they may be depressed, may stop social life/work life…And remember, now we have so many young patients, in their 20s and 30s due to early use of Gutkha etc.
3. Outcome: Due to close proximity of critical structures, it is difficult to achieve good negative margins, if surgeon does not have sufficient training and experience for this region. Hence there is high risk for recurrence from inadequate surgery. There is no role for DEBULKING surgery in this region.
Also, few of the operable patients may be labeled as unresectable resulting in markedly reduced survival. For example, skull base region is one such area where many patients are labeled as inoperable and sent to palliative care, where in fact new surgical techniques can completely resect the disease.
When choosing a surgeon, one should consider above points. And yes they are available in India, as increasingly cancer surgeons are specializing region wise, either as part of training or in practice. Most institutes/cancer centers do not have anyone now in “general cancer surgery”. As the medical field is maturing in India, all cancer surgeons are slowly specializing region wise.
It is also important to assess the reconstruction specialist/plastic surgeon working in his/her team when choosing a surgeon. Now there are so many new techniques in this field to enhance overall outcome, such as various skin flaps (including nearby skin soft tissue OR distant flaps known as free flaps using advance microvascular surgeries), bone reconstruction (using bone from other parts like fibula, prosthetics etc).
May 15th 2015.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com