Nonsurgical Treatment

Effective radiotherapy requires careful simulation and treatment planning. The patient generally lies supine while the head is immobilized with the neck extended using a headrest and customized mask. A tongue blade is inserted to depress the tongue away from the palate, and palpable lymph nodes are outlined with wires. The most common field arrangement consists of opposed lateral fields to encompass the primary tumor and upper neck (Figure 7-3). A third, anterior field is matched below the...

Contributors

Andersen, MD, FACS Associate Professor Department of Otolaryngology, Head and Neck Surgery Oregon Health Sciences University Portland, Oregon Memorial Sloan-Kettering Cancer Center Assistant Professor Department of Otorhinolaryngology Head and Neck Surgery Weill Medical College of Cornell University New York, New York Oral Cavity Cancer John F. Carew, MD Assistant Attending Surgeon Department of Otorhinolaryngology Head and Neck Surgery New York Presbyterian Hospital Assistant...

Psychosocial Impact

The psychosocial impact of a cancer diagnosis and its treatment often supersede the physical consequences of treatment. Psychosocial issues can be addressed via several different domains including emotional well-being, role functioning, social relations, sexuality and assessment of anxiety or stress. Affected patients have increased psychosocial stressors with resultant increases in depression and suicides.58 One study found that cancer patients accounted for one-quarter of all hospital-based...

Anatomy and Diagnosis

Esthesioneuroblastoma or olfactory neuroblastoma is a malignant tumor of the superior nasal vault that arises from the olfactory neuroepithelium and has a bimodal age distribution with peaks in the second and sixth decades.90 These rare tumors can cause vague symptoms that include epistaxis, nasal obstruction, and headache, with expansile and invasive growth leading to malar swelling, dental pain, proptosis, diplopia and increased intracranial pressure.19 While these tumors exert the majority...

Basal Cell Carcinoma

Basal cell carcinomas (BCC) account for the vast majority of non-melanoma skin cancers (75 ) and well over 25 percent of all cancers diagnosed in the United States each year.49-51 Five clinical histopathologic subtypes of basal cell carcinoma have been described of which nodular ulcerative is most common, followed by pigmented, superficial, morphea-like, and fibroepithelioma. 51 BCC has a predilection for fair-skinned individuals but can occur in Latin American and African American patients.52...

Benign Tumors

These tumors arise from the skin appendages and can show pilosebaceous, eccrine, or apocrine differentiation. Common benign adnexal tumors include nevus sebaceous, trichoepithelioma, pilomatricoma, cylindroma, syringocystadenoma papilliferum, syringoma, and eccrine spiradenoma. Nevus sebaceous tumors are congenital hamar-tomas of the skin that probably arise from basal cells. These lesions typically involve the face and scalp regions of children, ranging in appearance from slightly raised...

Bernard B Omalley Md

Imaging the neck is unlike imaging any region of the torso or brain since maximal contrast resolution is necessary to differentiate lesions in cross-sectional exams of those solid organs. Because of the various organ systems, the neck has very good native contrast resolution between lesions and adjacent normal structures and at the interface with the skull base and thoracic inlet. Intravenous contrast is necessary, however, to differentiate veins (and arteries) from adenopathy and masses...

Buccal Mucosa Retromolar Trigone Hard Palate

Diagram of the oral cavity and subsites. upper lip possesses two peaks forming a cupid's bow where the filtrum ascends to the columella of the nasal septum. The orbicularis oris muscle receives motor innervation from the marginal and buccal branches of the facial nerve and performs a sphincteral function to maintain oral competence and to facilitate articulation of speech. This muscle has many attachments from other muscles of facial expression that elevate and depress the lips. Of...

Case 6 Rhomboid Flap

This versatile geometric flap was described by Limberg, a mathematician. It can be used in many areas of the body and provides a satisfactory closure of surgical defects, particularly in patients with lax skin. The patient shown in Figure 4-10A was referred having undergone excisional biopsy of a malignant melanoma of the cheek. The scar of previous surgery was widely encompassed in the surgical incisions which were planned to provide access for superficial parotidectomy at the same operation....

Clinical Presentation And Diagnosis

Small tumors at certain sites, such as the crypts of the tonsils, the glossotonsillar sulci and the tongue base rarely produce symptoms and are not always easy to detect. When present, the initial symptoms of oropharyngeal cancer are often vague and nonspecific, leading to a delay in diagnosis. Consequently, the overwhelming majority of patients present with locally advanced tumors. Presenting symptoms may include sore throat, foreign-body sensation in the throat, altered voice or referred pain...

Condylar Reconstruction

The condyle is sometimes resected in combination with the ramus and angle of the mandible for tumors which originate in the lateral pharynx, external skin, or parotid gland. In cases where the condyle is not involved with tumor it is preferable to transplant the proximal 2.0 to 2.5 cm of condyle back onto the reconstructed mandible using titanium plates and screws.35 An intraoperative frozen section of the Figure 19-5. A, A 49-year-old woman with a recurrent parotid tumor after receiving...

Diagnosis Symptoms

Mass Hard Palate

Nasal cavity and paranasal sinus malignancies often do not cause symptoms until they have expanded to a significant size or have extended through the bony confines of the sinus cavity. These tumors therefore tend to present at a more advanced stage. Symptoms may initially include nasal obstruction, epistaxis, pain, and episodes of sinusitis. Tumor expansion inferiorly towards the oral cavity may be associated with swelling of the gingiva or palate with loose teeth, while orbital invasion may...

Fibroepithelial Polyp

Also known as skin tags, fibroepithelial polyps typically develop in middle-aged persons and are of limited consequence. These lesions are usually removed for cosmetic reasons, although they may become quite large and symptomatic due to irritation or trauma. The pedunculated lesions are usually fleshy and are composed of an epithelial covering and a fibrovascular core. Occasional case reports have demonstrated the presence of coexistent carcinoma but this is rare, with one series showing only 5...

General Principles

Treatment of tumors of the oropharynx has the potential to cause significant functional deficit, and the optimal treatment plan must strike a balance between minimum functional derangement and long-term disease-free survival. Surgery or radiation therapy, alone or in combination, are currently accepted as standard treatment for oropha-ryngeal cancer. Other modalities such as chemotherapy must be considered experimental and are generally reserved for patients with advanced or recurrent disease...

Jo

The extra-adrenal paraganglia are neural crest-derived rests of tissue that migrate to sites in the body in close association with cranial nerves, the aorta and its branches.48 These paraganglia are composed of two predominant cell types the sustentac-ular cells and the chief cells. The sustentacular cells are modified Schwann cells whereas the chief cells produce and can release catecholamines and other neurotransmitter substances.19,48 The tumors that arise from these cell rests, the...

Latissimus Dorsi Flap

The latissimus dorsi (LD) muscle originates from the six caudal thoracic spines and fascia, the lumbar spines and fascia, and the posterior iliac crest. It inserts into the humerus. Its blood supply is from the thoracodorsal artery, accompanied by the thora-codorsal vein and nerve. The neurovascular pedicle enters the undersurface of the muscle 6 to 11.5 cm distal to the origin of the subscapular artery and 1.0 to 4.0 cm medial to the anterior border of the muscle. The thoracodorsal artery...

Local Flaps

Local flaps consist of tissue that is mostly detached from surrounding tissue but retains enough connec Figure 18-6. A, A patient with dermatofibrosarcoma of the scalp was reconstructed with pericranial flap and split-thickness skin graft which have healed well. B, Tissue expander in place and scalp fully expanded. C, Appearance after excision of skin graft, removal of tissue expander and advancement of expanded scalp. tion to preserve an adequate blood supply to the entire flap. These are...

Malignant Melanoma

The incidence of malignant melanoma in the United States increased by approximately 69 cases per year during the 1970s and by approximately 39 cases per year during the 1980s and 1990s.70 The death rate from melanoma, however, has not changed during that period, suggesting the impact of more aggressive efforts at early detection. Approximately 20 percent of these tumors involve the head and neck region and occur in patients in their fifth and sixth decades of life.71-73 Like non-melanomatous...

Maxillary Defects and Obturators

Tumors that require maxillary resection will create defects of the maxilla, palate, or adjacent soft tissue. They can range from small perforations of the hard or soft palate to extensive resections (eg, the maxilla, the soft palate, and such adjacent structures as the orbit and cheek). Defects of these regions can lead to a variety of sequelae. Hypernasality renders speech unintelligible. Mastication can be difficult, particularly for the edentulous patient, because dental structures and...

Midfacial Combined Oral and Facial Defects

Large combination defects of the oral cavity and the external face create a challenge for the patient and the maxillofacial prosthodontist. Many of these patients previously have had numerous minor surgical removals and have had these tumors over a long period of time. In addition, when the integrity of the oral cavity has been compromised, food and air escape during swallowing, speech often is unintelligible, and saliva control is difficult52 (Figures 20-15 and 20-16). Many facial defects...

Muscle And Musculocutaneous Flaps

The development of muscle and musculocutaneous flaps resulted from an understanding of the blood supply to muscles and their overlying skin segments.26,27 This development in reconstructive surgery has significantly maximized flap survival and allowed reconstruc tion of larger head and neck defects that could not be covered with local flaps alone.28 A complete muscle or a muscle segment may be rotated or transposed into a defect, based on its own inherent blood supply. The muscle surface may be...

Paramedian Forehead Flap

This axial flap is commonly used for external coverage in nasal reconstruction. It is based on the supra-trochlear artery and vein, running on the undersur-face of the flap.19 The flap is designed using a precise template of the missing nasal subunits and is placed on the contralateral forehead. Usually the distal third of the flap is elevated subcutaneously the middle third includes part of the frontalis muscle, and from 1 cm above the supraorbital rim, flap elevation is in the subperiosteal...

Rectus Abdominis

Various designs of musculocutaneous flaps may be transferred as free flaps based on the rectus abdominis muscle, supplied by the deep inferior epigastric artery and vein and the periumbilical perforators69 (Figure 18-28). The rectus abdominis muscle is flat and thin, with a large skin island over the muscle that may be oriented in a vertical transverse or oblique fashion. In addition, one or more cutaneous paddles may be used to cover multiple surfaces of complex multidimensional defects in the...

References

Greenlee RT, Hill-Harman MB, Murray T, Thun M. Cancer Statistics, 2001. CA Cancer J Clin 2001 51 15-36. 2. Rhys Evans PH. Tumours of the oropharynx and lymphomas of the head and neck. In Kerr AG, editor. Scott-Brown's otolaryngology, Volume 5, 6th Ed. London Butterworth 1997. 3. Guillamondegui OM, Meoz R, Jesse RH. Surgical treatment of squamous cell carcinoma of the pharyngeal walls. Am J Surg 1978 136 474-6. 4. Lindberg RD, Barkley HT, Jesse RH, Fletcher GH. Evolution of the clinically...

Risk Factors and Etiology

Soft-tissue sarcoma of the head and neck (STSHN) is a disease most prevalent in adults and none of the risk factors commonly associated with squamous cell carcinoma are known to be involved in the pathogenesis of these tumors. Epidemiologic studies have identified genetically predisposed groups of individuals such as those suffering from neurofibro-matosis who are at risk of malignant peripheral nerve sheath tumor (MPNT), people with the Li-Fraumeni syndrome and children with retinoblas-toma...

Sequelae and Rehabilitation

The morbidity of surgical resection of tumors of the middle cranial fossa, irrespective of the surgical approach that is chosen, relate to paralysis or paresis of the lower cranial nerves as well as the facial mimetic musculature.52 If vagus nerve injury or sacrifice occur, paralysis of the pharynx, palate, and the vocal cord will ensue. In many instances, the initial breathiness and aspiration of liquids that can occur will gradually resolve as there is compensatory movement of the...

Sequelae Complications And Their Management

Although modern anesthetic and surgical technique has greatly increased the safety of surgery for oropharyngeal tumors, careful planning and meticulous technique are vital to successful outcome. The most common complications of surgery arise due to difficulties associated with inadequate exposure and the failure to anticipate the need for reconstruction. Incisions must be planned to take previous surgery and or radiation into consideration. It is important to resist the temptation to close a...

Soft Palate Speech Bulb Prostheses

Defects of the soft palate usually require maxillofa-cial prosthetic intervention. Palatopharyngeal closure normally occurs when the soft palate elevates and contracts the lateral and posterior pharyngeal walls of the nasopharynx.27 When a portion of soft Figure 20-8. A, Six months post-maxillectomy. B, Definitive obturator. C, Definitive obturator in occlusion. palate is excised or when the soft palate is perforated, scarred, or neurologically impaired, complete palatopharyngeal closure cannot...

Subglottic Larynx

Primary subglottic larynx cancers account for only 4 to 6 percent of all larynx cancers. Most lesions involving the subglottic region represent transglottic extension of glottic malignancies. It is uncommon for primary subglottic cancers to present at an early stage as they are asymptomatic until quite advanced. The risk of lymph node metastasis is 20 to 30 percent with bilateral involvement being common. T1 lesions are those that are confined to the subglottis and T2 lesions involve the vocal...

Supraglottic Larynx

T1 lesions are limited to one subsite with a normal vocal cord mobility. T2 lesions invade the mucosa of more than one adjacent subsite of the supraglottis or the glottis, vallecula, mucosa of the base of tongue, or the medial wall of the pyriform sinus, but do not have fixation of the larynx. The incidence of lymph node metastasis is high at 25 to 50 percent. The risk for bilateral nodal involvement is substantial as well. These early stage lesions are highly curable by either surgery or...

Surgical Treatment

The type of surgical resection required for tumors of the nasal cavity and paranasal sinuses is dictated by each lesion's anatomic location and sites of extension. Tumors originating in the maxillary sinus are removed by some form of maxillectomy. Several different subtypes of maxillectomy have been described, each characterized by the extent of the maxilla resected with tumor. Although terms such as limited, partial, medial, subtotal, total, radical, and extended have been used to...

The Algorithm For Reconstruction of Mandibular Defects

Scapular Soft Tissue Flap

Our experience clearly indicates that osseous free flaps have a very high success rate and should be used for most primary mandible reconstructions. The functional and esthetic outcomes are good-to-excellent for the majority of patients. The algorithm for flap selection is driven principally by the extent and site of bone and skin soft tissue loss. (Figure 19-7). The fibula donor site should be the first choice for a vast majority of patients, particularly those with large bony defects...

Tumors And Cysts Of The Dentoalveolar Structures

About 9 percent of all tumors in the oral cavity are odontogenic and may differentiate toward epithelial or the odontogenic ectomesenchymal line and are classified accordingly (Table 2-5). They are predominantly benign with rare exceptions. Ameloblastoma is a locally aggressive, usually intraosseous tumor of odontogenic epithelium most commonly involving the posterior part of mandible and sometimes the posterior maxilla. The tumor affects both sexes at all ages, with a higher incidence in the...

Cancer of the Nasopharynx

Nasopharyngeal carcinoma is rare in the United States, with an annual incidence of 0.6 per 100,000 people. The incidence in Southern China is 50 times higher than in the United States.1 Native people of North Africa, the Middle East, Alaska, and Malaysia have an intermediate risk. The peak incidence for this cancer occurs in the fourth to fifth decade of life but it may occur in children and in the elderly. The male to female ratio is 2 to 3 1. The etiology of nasopharynx cancer is thought to...

Differentiated Thyroid Cancers

The two primary types of differentiated thyroid cancers are papillary and follicular. Several variants exist and include a follicular variant of papillary carcinoma, a tall cell variant of papillary carcinoma and a Hurthle cell carcinoma which is a variant of follicular carcinoma. The latter two subtypes are more ominous lesions. Primary surgery is the initial treatment approach. The surgical therapeutic decisions are based on prognostic variables. At Memorial Sloan-Kettering Cancer Center,...

Types of Therapeutic Radiation

There are two main categories of ionizing radiation and each contains several subtypes of clinical importance (1) electromagnetic radiation (photons) x-rays, gamma rays, and (2) particulate radiation electrons, neutrons, protons. The electromagnetic radiation subtypes do not differ in any physical characteristic or in their biologic action. The only distinction is in how they are each produced. X-rays are created by linear accelerators and involve an electrical input that causes a filament to...

Role of Chemotherapy and Organpreserving Approaches

Although numerous randomized trials have failed to demonstrate any survival benefit for neoadjuvant or sequential chemotherapy schedules, the major spinoff of the neoadjuvant approach was the observation that function of important structures such as the larynx and tongue could be preserved without compromising local control or survival.26 More recently, the radiosensitizing effects of chemotherapy have been exploited in designing concurrent chemoradiation protocols, and 3-year local control...

Chemotherapy and Radiotherapy

Treatment protocols using chemo RT to preserve organ function have successfully demonstrated their ability to anatomically preserve the larynx without compromising survival. One aspect of these protocols that is often underappreciated is the functional capacity of the retained organs. Few investigators have clearly documented the functional sequelae of chemotherapy and radiation therapy. Recently, Lazarus retrospectively studied patients being treated with chemotherapy and radiation therapy and...

Chemotherapy for Advanced Tumors

In attempts to improve the survival rates and local control of advanced sinonasal tumors, chemotherapy has been administered as an adjuvant treatment in a wide variety of methods. Chemotherapy has been given (1) with radiation and daily tumor debridement,33-36 (2) by topical application,35 (3) selectively to the head and neck through intra-arterial infusion,3337-39 (4) as a neoadjuvant treatment prior to further local treat-ment,40-42 and (5) concomitantly with hyperfraction-ated radiation...

Chemotherapy with Maxillary Debridement

Chemotherapy has been incorporated into numerous different treatment regimens with varying agents, methods of delivery, and combinations with radiation and or surgery. In the 1970s several groups in Japan began trying a combination of chemotherapy, radiation therapy and routine tumor debridement or cryosurgery within the maxillary sinus. The regimens included 5-fluorouracil (5-FU) or cisplatin with delivery through intravenous,3436 selective intra-arterial,33 and topical methods.35 Responses to...

Neoadjuvant or Concurrent Chemotherapy

Despite the encouraging results described above, both routine tumor debridement and intra-arterial cannula-tion present technical demands and may not be available for widespread use. Chemotherapy may be administered intravenously as a neoadjuvant agent prior to treatment with other modalities. LoRusso gave 24 patients with stage III or IV disease various chemotherapy combinations, including 5-FU and cisplatin, and followed this with surgery and or radiation therapy. Overall 5-year survival was...

Chemotherapy and Chemoprevention in Head and Neck Cancer

MALUF, MD ERIC SHERMAN, MD DAVID G. PFISTER, MD For most epithelial tumors of the head and neck, surgery and or radiation therapy have historically been the principal treatment modalities. Systemic drug therapy alone in most instances does not have curative potential, and previously had been reserved for the palliative treatment of recurrent and or distant metastatic disease. Over the last decade, this has changed dramatically, especially for squamous cell carcinomas of the upper...

Chemotherapy for Salivary Gland Cancers

Major and minor salivary gland cancers represent approximately 5 to 10 percent of head and neck malignancies.134 135 In general, surgery and or radiation have been the principle treatment modalities, with chemotherapy primarily used in the recur-rent metastatic disease setting. As a single modality, chemotherapy is not curative. Because of the relative rarity and heterogeneity of these tumors, the available data on the efficacy of systemic therapy is often of poor quality. Many series are...

Neurogenic and Vascular Tumors of the Head and Neck

SHAH, MD, FACS Neurovascular tumors of the head and neck are a varied group of neoplasms that can present clinically as isolated masses or in association with various familial syndromes. The majority of neurovascular tumors are benign lesions that can potentially exhibit local destruction from expansile growth, while some are overtly malignant, with aggressive growth capabilities and obvious metastatic potential. While the treatment for these lesions is...

Cancer of the Hypopharynx and Cervical Esophagus

The management of malignant neoplasms of the hypopharynx and cervical esophagus remains difficult despite recent advances in surgical techniques as well as multidisciplinary treatment programs. Many patients present at a later age with advanced disease due to the occult nature of associated symptoms. The disease process and treatment often affect adjacent structures, such as the larynx. Regardless of the type of therapy employed, high recurrence rates, poor survival, and significant alterations...

Chemotherapy for Thyroid Cancer

As with salivary gland tumors, thyroid cancer constitutes a spectrum of histologic subtypes and clinical Table 22-10. COMBINATION CHEMOTHERAPY IN SALIVARY GLAND CANCER CDDP 5-FU CDDP DOXO 5-FU CDDP EPI 5-FU or CTX CTX DOXO CTX DOXO CDDP Adenoid cystic Mucoepidermoid Mucoepidermoid 'Variable 'Variable 'Variable 'Variable * Variable includes adenoid cystic carcinoma and mucoepidermoid carcinoma as the most common histologies. BLM bleomycin CDDP cisplatin CT chemotherapy CTX cyclophosphamide DOXO...

Rehabilitation and Quality of Life Assessment in Head and Neck Cancer

In 1947, the World Health Organization (WHO) expanded its definition of health beyond the absence of disease and infirmity, to include the state of physical, mental, and social being. This milestone change in connotation elevated the study of health-related quality of life to an accepted endpoint for clinical studies and promulgated investigator interest.1,2 Reflecting its increased use in medical studies, quality of life was introduced as a category in the Index Medicus in 1966.1 Since then,...

Neutron Therapy

This densely ionizing high linear energy transfer particulate radiation has a limited but important role in clinical radiation oncology. Fast neutrons can be contrasted to photons in th following ways 1. the biologic effectiveness is much less influenced by hypoxic environments. 2. lethal effects are less dependent on the cell cycle phase. 3. the ability of malignant cells to repair sublethal damage matters less. 4. is biologically more effective with a relative biologic effectiveness (RBE) of...

Factors Affecting Choice of Treatment

Because of anatomical constraints and the radiosen-sitivity of carcinoma of the nasopharynx, primary surgical resection is not indicated. Radiation therapy is the principal treatment modality for curative therapy and may also be used to palliate local symptoms. Chemotherapy has been studied as an adjuvant to primary radiotherapy and serves as systemic treatment for patients with disseminated disease. The basic treatment of nasopharynx cancer has consisted of radiation therapy alone for many...

Cancer of the Head and Neck

Shah, MD, MS (Surg.), FACS, Hon. FRCS (Edin), Hon. FDSRCS (Lond) Chief, Head and Neck Service E.W. Strong Chair in Head and Neck Oncology Memorial Sloan-Kettering Cancer Center Professor of Surgery, Weill Medical College, Cornell University New York, New York Assistant Editor Snehal G. Patel, MD, MS (Surg.), FRCS Clinical Research Associate Head and Neck Service Memorial Sloan-Kettering Cancer Center New York, New York 2001 BC Decker Inc Hamilton London BC Decker Inc 20 Hughson Street...

Glottic Larynx

Squamous cell carcinoma in situ of the true vocal cords is initially treated surgically, and usually with micro-excision. However, if there is evidence of microinvasive squamous cell carcinoma in the specimen or if there are rapid or multiple recurrences, radiation therapy can be administered with an approach identical to that for T1 invasive lesions. Wang24 reported a 92 percent 5-year local control and a 98 percent 5-year disease-free survival. The results in voice quality are good. T1...

Relationship of Cell Cycle and Ionizing Radiation

The cell cycle (Figure 21-2) has four phases that are distinctly sequenced and describe the life cycle of cells (1) Synthesis (S) DNA synthesis, (2) Gap (G2) a period of apparent cellular inactivity, (3) Mitosis (M) cellular division into two daughter cells, (4) Gap (G1) a period of apparent cellular inactivity. Cells vary in their sensitivity to ionizing radiation and this is dependent on their position within the cell cycle at the time of the exposure to the radiation (Figure 21-3). The most...

Concomitant Chemotherapy

The concomitant integration of chemotherapy and radiation therapy for the treatment of advanced disease has been one of the areas of greatest interest in head and neck oncology during the last decade. Potential radiation enhancement, the simultaneous treatment of both locoregional and distant disease in a dose-intense manner, and shorter treatment times make the approach particularly appealing. Interestingly, the approach is much older than the relatively recent surge in interest would suggest....

Selective Intraarterial Chemotherapy

The selective administration of chemotherapy through intra-arterial infusion offers the advantage of a more direct drug delivery to the tumor site at a higher local concentration than can be achieved with systemic therapy. This technique was initially attempted with modest results similar to those obtained by surgery and postoperative radiation ther-apy.53 Shibuya suggested that one problem was the multiplicity of feeding arteries supplying the maxillary sinus causing an irregular, lower...

Soft Tissue Tumors

Enhancing Scalp Cutaneous Lesion

Histologic typing and grading of STS is often difficult and a considerable degree of inter-observer variability exists even among expert pathologists with a reported diagnostic discrepancy in as many as 25 to 40 percent of lesions.12 The routine use of immunohistochemical stains has facilitated histologic classification, but these techniques are by no means definitive, and considerable experience is required in interpreting results. More objective methods such as cytogenetic, molecular and...

Bone Tumors

Orbital Cancer Invasion

Bone tumors are generally classified according to the matrix that their constituent cells produce eg, tumors that produce a cartilaginous matrix are classified as chondrosarcomas, those that produce osteoid are classified as osteosarcomas and others that lack a distinct matrix may be classified as fibrosarcomas. Chondrosarcomas and osteosarco-mas are by far the most common sarcomas involving the facial skeleton, but other rarer types such as Ewing's sarcoma and peripheral primitive...

Outcomes and Results of Treatment

The prognosis for sinonasal malignancies has remained poor for the past several decades despite refinements in both surgical technique and radiation therapy. Stern reviewed the M.D. Anderson experi- Figure 11-16. An intraoral view of a rectus abdominus free flap filling a left total maxillectomy defect. Facial contour following total maxillectomy is improved by the soft-tissue bulk of a rectus abdominus free flap reconstruction. Figure 11-16. An intraoral view of a rectus abdominus free flap...

Treatment Goals and Treatment Alternatives The Role of Multidisciplinary Treatment

Cure is the goal of treatment for most patients without distant metastases. Prognosis depends upon disease stage, histology, and biological factors such as degree of angiogenesis.9,14-16 Palliation of symptoms is a secondary goal for patients with curable disease and a primary goal for patients with distant metasta-tic disease. Palliative approaches range from supportive care to chemotherapy, radiation therapy and, rarely, surgical intervention. The optimal management of nasopharynx cancer...

Rehabilitation

The rehabilitation of function after oral surgery is a critical element in effective oral cancer surgery. After major oral resections the patients need rehabilitation of speech, swallowing, dentition and mastication as well as cosmesis. This process is best accomplished in a multidisciplinary environment which include the head and neck surgeons, plastic surgeons, speech and language therapists, nurses, dentists, prosthodontists and oral and maxillofacial surgeons. Perhaps the most important...

Sequential Chemotherapy

The sequential integration of chemotherapy with locoregional treatment can be done in three main ways as induction or neoadjuvant chemotherapy prior to surgery and or radiation, as an adjuvant after locoregional treatment, or as a combination of these approaches. Given the impressive response rates Table 22-1. PHASE I II TRIALS EVALUATING NEW CHEMOTHERAPEUTIC COMBINATION REGIMENS'ACTIVITY IN PREVIOUSLY UNTREATED PATIENTS WITH LOCALLY ADVANCED HEAD AND NECK CANCER Table 22-1. PHASE I II TRIALS...

Management of Leukoplakia

Effects Smoking Alveolar

During the carcinogenic process, some abnormal clonal populations of mucosal cells form clinical premalignant lesions. These are manifested as leukoplakia or erythroplakia. Leukoplakias are common lesions in smokers and patients with a previous history of head and neck cancer. These are also noted in patients without heavy carcinogenic exposure. In general, dysplastic leukoplakia should be treated while lesions harboring only hyperplasia and hyperkeratosis may be observed. Clinical...

Management of Cervical Metastasis

Postauricular Injection

ANDERSEN, MD, FACS SCOTT SAFFOLD, MD Head and neck cancer represents less than 5 percent of all cancers in the United States and will be responsible for approximately 11,800 deaths in 2001.1 However, worldwide it ranks as the sixth most common cancer,2 thus making head and neck cancer a major health problem. While the term head and neck cancer refers to tumors of myriad sites of origin and histologic types, over 90 percent of these are squamous carcinomas arising from the epithelium of...

The Role of Chemotherapy in Larynx Organ Preservation

Laryngeal Cancer Treatment

The trials evaluating induction chemotherapy, while disappointing with regard to improving survival as an endpoint, did provide the backdrop for current organ preservation strategies. Investigators observed that some patients refused surgery after initial chemotherapy and proceeded with radiation alone.87 Some of these patients were controlled over the long term without surgery, and there appeared to be a positive correlation between initial response at the primary site to induction...

General Principles of Reconstructive Surgery for Head and Neck Cancer

DISA, MD ERIC SANTAMARIA, MD PETER G. CORDEIRO, MD, FACS Current treatment of head and neck cancer follows a multidisciplinary approach. The principle of this combined approach is to provide the patient with the optimal cancer treatment for the stage of disease, and to maximize the quality of life for the patient, with preservation or restoration of form and function. Reconstructive surgical procedures developed over the past several decades have substantially contributed to attain...

General Considerations

Treatment of head and neck cancers has oral sequelae and treatment-related toxicities requiring intervention by dentists. Dental team intervention should begin prior to radiation therapy, surgical resection, and or chemotherapy. For optimal post-treatment oral functional outcomes, regardless of cancer therapies, a comprehensive dental assessment is para-mount.1 The multidisciplinary team should encompass trained dentists with interests and training in comprehensive oral dental care of the...

Cancer of the Nasal Cavity and Paranasal Sinuses

KRAUS, MD, FACS Cancers of the nasal cavity and paranasal sinuses are rare, comprising less than 1 percent of all human malignancies and only 3 percent of those arising in the head and neck.1 Sinonasal malignancies occur twice as often in males as in females, and are most often diagnosed in patients 50 to 70 years of age.2 The majority of these tumors are squamous cell carcinoma, although a wide variety of other malignancies including sarcoma, adenoid cystic...

Quality of Life Instruments

As the science of QOL assessment has matured, standardized testing has been implemented to validate QOL instruments, centered on establishing reliability, validity, and normative data.1 Reliability can best be defined as the usability of a particular instrument, which can be divided into four concepts namely test-retest reliability, alternate-form reliability, internal consistency, and interobserver reliability. Test-retest reliability measures the stability of the test over time. Typically,...

Clinical Course of Radiation Therapy

Xerostomia After Radiation

The patient undergoing radiation therapy will need to be seen for routine status evaluation at least once a week. At that time, a pertinent interval history is obtained with special attention paid to the development of a sore mouth or throat, dysphagia, hoarseness, taste problems, xerostomia, skin symptomol-ogy, and even ear symtoms when the portal includes the external auditory canal and or eustachian tube. A directed examination will evaluate the tumor status with measurements and an...

The Larynx Early Stage Disease

Cancer Larynx Disease Pathophysiology

LYDIATT, MD, FACS DANIEL D. LYDIATT, DDS, MD, FACS The American Cancer Society estimated that in the United States there would be 10,600 cases of laryngeal carcinoma diagnosed in 1999, and 4,200 deaths.1 This accounts for 0.9 percent of cancers from all sites and 0.8 percent of all cancer deaths. Laryngeal carcinoma makes up 1 to 2 percent of cancers worldwide, and the incidence is increasing (Figure 9-1). Spain has one of the highest rates in the world with Basque and Navarra...

Pathology of Head and Neck Tumors

Cancer Tumors Body

HUVOS, MD TUMORS OF THE UPPER AERODIGESTIVE TRACT MUCOSA Neoplasias of the upper aerodigestive tract histologically tend to mimic the normal constituent cells in this region. The most common neoplasias show differentiation toward lining epithelium. pressure. Synchronous or metachronous association with squamous cell carcinoma as well as progression to it may occur in some patients with inverted Squamous papilloma is a solitary papillary lesion of the squamous...

Thyroid and Parathyroid Tumors

Thyroid Berry Ligament

PATEL, MD, MS, FRCS Diseases of the thyroid gland represent a common medical and surgical problem. A variety of inflammatory lesions and neoplasms are noted by endocri-nologists and surgeons interested in thyroid pathology. Various pathologic conditions include Hashimoto's thyroiditis, nodular goiter, solitary thyroid nodule, adenomas and thyroid cancer. Although thyroid disease is extremely common, thyroid cancer is relatively uncommon and forms less than 2...

Epidemiology and Etiology

Oral Cancer Risk Smoking And Alcohol

The global incidence of cancers of the oral cavity, pharynx and larynx is about 500,000 cases per year with mortality of 270,000 cases per year.1 Excluding skin cancers, this represents about 6 percent of the incidence and 5 percent of the mortality of all cancers.1 About three-fourths of these are cancers of the oral cavity and pharynx and the remainder are laryn-geal cancers. Figure 1-1 describes the incidence of oral and pharyngeal cancers by world region. As demonstrated here, the areas of...

Case 7 Bilobed Flap

Necrotic Wound

The bilobed flap is a random flap but is excellent for coverage of various surgical defects throughout the Figure 4-10. A, The patient had undergone excisional biopsy of a malignant melanoma of the cheek elsewhere. The scar of previous excision was widely encompassed in the surgical incisions which were planned to provide access for a superficial parotidectomy. B An inferiorly based cervical Limberg flap has been elevated and the surgical bed of resection shows the branches of the facial nerve...

Patient Education Home Care Instructions Fluoride Application

Fluoride Trays For Radiation Therapy

Oral hygiene procedures including scaling, polishing, sub-gingival root planing and curettage should be performed and home-care instructions and fluoride prescriptions given between the initial screening appointment and commencement of external beam radiation therapy (EBRT).7 In addition, overhanging and faulty Figure 20-2. Full mouth extractions post-radiation therapy with alveolectomy and primary closure. Figure 20-2. Full mouth extractions post-radiation therapy with alveolectomy and primary...

Surgical Treatment Resection

Pictures Esophageal Reconstruction

The difficulty in surgical treatment of advanced carcinoma of the hypopharynx and cervical esophagus arises from the common requirement for laryngectomy as part of the procedure. The larynx is removed because of direct or submucosal tumor extension and significant risk of chronic or life-threatening aspiration. Histopathologic studies of hypopharyn-geal cancer have shown that assessment of the extent of laryngeal disease based on endoscopic findings in the hypopharynx is inaccurate.50...