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...

Alternatives The Role of Multidisciplinary Treatment

In the last 2 decades, 5-year survival of patients with laryngeal cancer has not changed dramatically.22 Maximizing survival, therefore, continues to be the ultimate goal in treating patients with advanced stage larynx cancer. Recently, however, due to the lack of improvement in survival, significant efforts have been made to improve the quality of life in these patients. Paramount to this is preservation of a functional larynx. Toward this goal, treatment options have been formulated with the...

Anatomic Considerations

The scalp is a unique adaptation of the epithelial covering of the body. Anatomical variations present in the scalp modify both tumor behavior and the treatment of tumors in this area. The hair-bearing area of the scalp consists of a thick padding of hair follicles, sweat glands, fat fibrous tissue and lymphatics that are interspersed with numerous arteries and veins (Figure 4-1). This thick padding is supported by a tough aponeurotic layer that is fused in the anterior region with the...

Anatomy

Schwannomas or neurilemmomas are solitary, predominantly benign, well-encapsulated tumors that arise from the Schwann cells of the peripheral nerve sheath.74 While these tumors can arise from nerves throughout the body, as many as one-half occur within the head and neck,75 and demonstrate a slight female predominance, presenting most commonly in the fourth and fifth decades.19 Within the head and neck, schwannomas can arise from the eighth cranial nerve (acoustic neuroma), the vagus nerve, or...

Anatomy and Diagnosis

Neurofibromas are non-encapsulated, peripheral nerve sheath tumors that cause a fusiform dilatation of their nerve of origin.19 While these tumors may occur as solitary, subcutaneous or submucosal masses, they more commonly present as multiple discrete tumor nodules or with extensive nerve sheath distortion (plexiform neurofibromatosis Figure 16-17) in association with one of the two forms of neurofibromatosis (NF). Neurofibromatosis type 1 (NF-1), also known as von Recklinghausen's...

Associated Medical Conditions

As hypopharynx and cervical esophagus cancer typically occur in older patients, associated medical con ditions are often present and should be included when considering treatment options. Although patients with weight loss more than 10 percent during the 6 months before surgery are at greater risk for the occurrence of major postoperative complications, cachexia and malnutrition are not contraindications to treatment due to improvements in nutritional assessment and delivery via enteral and...

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...

Benefits Drawbacks

The benefits of postoperative radiation therapy include (1) no delay in surgery, (2) no radiation dose limitations, (3) no influence on the extent of initial surgery, (4) no effect on wound healing, (5) allows for a full surgical and histopathologic evaluation of the extent of the tumor and lymph nodes, and (6) sterilization of residual microscopic disease which can result in improved local control. A possible drawback to this approach would be the potential for delay in initiation of radiation...

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...

Carcinoma in Situ

Irradiation or microsurgical excision (with or without a laser) of localized lesions can provide local control rates of 50 to 90 percent44-48 (Table 9-4). Murty and colleagues reported 75 percent local control with microsurgery.44 Twenty-five percent of the patients formed a glottic primary and were subsequently managed with radiotherapy. One of these patients failed and died of local failure. Nguyen and colleagues employed both surgical excision and radiation therapy and found a 50 percent...

Case 10 Island Pedicle Flap

Island pedicle flaps with their vascular pedicles can be isolated in various locations in the head and neck area. One of the most versatile and easily available island pedicle flaps is based on the anterior branch of the superficial temporal artery and vein which provides blood supply to the forehead. This flap is elevated from the lateral aspect of the forehead. Its advantages include fairly regular and identifiable artery and vein, a long vascular pedicle, and thick forehead skin to provide...

Case 2 Excision of Scalp Tumor with Advancement Rotation Flap

Surgical excision of tumors in the non-hair-bearing areas of the scalp requires coverage of the surgical defect with tissues that resemble the normal tissues in the area for a satisfactory esthetic appearance. Although split-thickness skin graft can be used to cover such surgical defects, its esthetic appearance is unacceptable. Advancement rotation scalp flaps provide a very satisfactory method of closure of such surgical defects. The defect is covered with the adjacent scalp while the donor...

Case 3 Excision and Fullthickness Skin Graft on the Nose

Nasal Skin Graft

This patient presented with Hutchinson's melanotic freckle (lentigo maligna) on the dorsum of the nose. The desired extent of excision is marked out with a skin marking pen and its dimensions are measured. The ideal donor site is the skin of the supraclavicu-lar region for a defect of this size. The postoperative appearance of the skin graft in this patient immediately after surgery is shown in Figure 4-6A and 6 months postoperatively in Figure 4-6B. Since sensations on this skin are absent,...

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....

Case 8 Mustarde Advancement Rotation Cheek Flap

Skin defects resulting from surgical excision of lesions involving the skin in the infraorbital region and medial part of the cheek are best suited for repair using a Mustarde flap. The major blood supply of this skin flap is from the posterior branches of the facial artery with the wide pedicle of the flap remaining inferiorly. A patient with a Hutchinson's melanotic freckle (lentigo maligna or in situ melanoma) presenting on the skin of the cheek in the right infraorbital region is shown in...

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...

Definition of Radiation

Radiation is energy which is emitted from atoms and is transmitted through space.1 It is the capture of this energy emanating from physical reactions occurring at an atomic level and its application to cellular material which results in biologic change that forms the scientific basis of the specialty of radiation oncology. There is a broad spectrum of radiation types, however the particular one of clinical interest is known as ionizing radiation. This is defined as radiation of sufficient...

Definitive Obturator Prosthesis

The definitive obturator prosthesis, usually fabricated 4 to 6 months after all cancer therapy is completed, should extend maximally along the lateral wall of the defect.25 The higher the lateral extension of the bulb, the greater is the increase in lateral stability of the prosthesis.26 When the definitive obturator prosthesis is completed, speech and swallowing are restored to normal limits (Figures 20-8 and 20-9). The patient is Figure 20-7. A, Preoperative squamous cell carcinoma posterior...

Diagnosis

What Dentascan

The diagnostic evaluation of a patient with oral carcinoma consists of the history and the physical examination, histopathologic tissue diagnosis, and imaging when indicated. The clinical history begins with the present illness and includes the duration and location of symptoms such as non-healing ulcer, mass in the oral cavity or neck, pain, bleeding, and any symptoms of cranial nerve deficits. A thorough exploration of the patient's past medical and surgical history, and the review of systems...

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...

Elective Neck Dissection

Elective treatment of cervical lymph node metastasis is generally recommended when the risk of occult disease is around 15 to 20 percent. Candela and colleagues demonstrated that the nodal groups at risk from laryngeal cancer are at levels II, III and IV.32 Level I was rarely involved in isolation and level V was never involved alone. This tends to support the removal of levels II, III and IV, the so-called jugular node dissection or lateral neck dissection, Surgical specimen from supracricoid...

Ethmoid Sinus

Lesions of the ethmoid sinuses tend to be of high grade and are associated with a significant risk for local recurrences despite negative margins. The generally preferred approach is with surgery and postoperative radiation therapy. Early lesions in the anterior ethmoid sinus can often be excised surgically. For involvement of the middle and or posterior ethmoid sinuses and for extensive disease, craniofacial resection and sometimes orbital exenteration may be necessary. Postoperative radiation...

Facial Defects

Restoration of the facial defect is a difficult challenge for both the surgeon and the maxillofacial prosthodontist. It is not uncommon for an advanced head and neck cancer to require a rhinectomy, orbital exenteration, loss of an ear or cheek, or a midface resection (nose, lip, palate). Both surgical reconstruction and prosthetic restoration have distinct limitations. The surgeon is limited by the availability of tissue and by damage to the local tissue bed. The maxillofacial prosthodontist is...

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...

Floor of Mouth

T1 and T2 lesions can be treated with surgery or radiation therapy. If there are clinically positive nodes, surgical resection of the primary lesion and a neck dissection is performed. Postoperative external beam radiation therapy may be indicated for close or positive margins in the primary site and or nodal disease. If radiation is to be given, both the floor of mouth and nodes are treated within 6 weeks after surgery to a dosage of 6,300 cGy to the primary site and high-risk node levels as...

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...

Head And Neck Surgical Resections Requiring Maxillofacial Prosthetics

Head and neck patients requiring surgical resections often require maxillofacial prosthetic rehabilitation, an integral component of head and neck cancer care. Restoration of speech, swallowing, control of saliva, mastication, and restoration of facial deficits are goals of maxillofacial prosthetic rehabilitation. Consultation between surgeon and maxillofacial prosthodontist during treatment planning can eliminate many unwanted sequelae. In many instances, proper surgical planning, and precise...

Imaging

Imaging studies are an essential component in the diagnosis, staging, and follow-up of sinonasal malignancies. Computed tomography (CT) scans give a good initial overview of the tumor's location with excellent bone detail (Figure 11-3). Because the paranasal sinuses and nasal cavity are mucosal-lined bony chambers, CT is helpful in determining whether a tumor remains confined within these natural boundaries or has eroded through the surrounding bone. CT provides details of the extent of local...

Improving the Therapeutic Ratio

The use of multiple fractions over many weeks of radiation therapy is based on the principle of improving the therapeutic ratio between normal tissues and tumors (Table 21-3). The goal is to maximize the cell death of tumors and to minimize unacceptable damage to normal cells. The radiobiologic mechanisms involved with causing cell death are similar for both normal and malignant cells. It is the differential ability of ionizing radiation to sterilize tumor while avoiding excessive normal tissue...

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...

Malignant Schwannomas

While the majority of schwannomas are benign in their clinical behavior, approximately 5 percent of them manifest malignant clinical behavior with a Figure 16-17. A, Plexiform neurofibromat. B and C, MRI of plexiform neurofibromat. small minority of these arising within the head and neck.74,83 These malignant variants can demonstrate high mitotic activity, aggressive local infiltrative growth with a high recurrence rate, pulmonary metastases, and direct intracranial extension.74,76,83,84 The...

Mandibular Defects

Malignant tumors associated with the lower gum, floor of mouth and adjacent structures also represent a difficult challenge for the prosthodontist with regard to rehabilitation after treatment. The disabilities resulting from such resections would include impaired speech articulation, difficulty in swallowing, deviation of the mandible during functional movements, and poor control of salivary secre-tions.33 Cosmetic disfigurement also can be present. These patients present a far more difficult...

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...

Nonsurgical Therapy

If one excludes carcinoma of the nasopharynx for which radiotherapy and chemotherapy are extremely effective (see chapter on Cancer of the Nasopharynx), there is a paucity of data on the use of non-surgical modalities specifically for the treatment of malignant tumors involving the middle cranial base. However, if one considers tumors of specific his tologies such as glomus tumors, neurilemmomas, and juvenile nasopharyngeal angiofibromas (JNAs), whose resection occasionally requires access to...

Operative Procedure

The surgical procedure commences with a bifrontal craniotomy. The bicoronal skin incision in the scalp is deepened to a level just superficial to the pericra-mum which is then incised approximately 5 cm posterior to the scalp incision. The galea and pericranium are elevated to the level of the supraorbital rims and the nasofrontal suture line, preserving the neurovascular (supraorbital) pedicle as it emerges from the supraorbital notch (Figure 12-2). Once this Figure 12-2. A, Incision for...

Oral Cavity

Oral cavity lesions rarely require imaging without clinical suspicion of deep infiltration. Patients with floor of mouth, retromolar gum and endophytic lesions of the tongue are imaged to rule out deeper involvement. Key landmarks are the midline lingual septum, mylohyoid sling, extrinsic muscles and cortical margin of mandible. Although axial images are most familiar, the coronal view is crucial for the above determination. The sagittal view is important to exclude extension of anterior tongue...

Oral Tongue

T1 and T2 local control rates are comparable between surgery and radiation therapy. For T1 lesions, there is a local control rate of 76 percent with surgery compared to 79 percent with radiation for T2 lesions, the rate is 76 percent with surgery and 72 percent with radiation.30 Surgery would generally be chosen as this approach is shorter, would obviate the acute and late side effects of radiation, and has a lower complication rate. Primary radiation therapy would include external beam...

Outcomes

Data regarding local and regional control as well as survival comes from retrospective series using radiation alone (Tables 7-2, 7-3 and 7-4). Overall outcomes in the United States have been substantially improved by the addition of chemotherapy (excluding stage I cancers) to radiotherapy. In the previ ously described study published by Al-Sarraf and colleagues, combined modality therapy resulted in a 3-year actuarial progression-free survival of 69 percent and overall survival of 78 percent....

Oxygen Effect

The ability of ionizing radiation to cause biologic change is very much dependent on the amount of oxygen present in the tissue environment. Oxygen is the most potent radiosensitizer known at this time. Cells in a 100 percent oxygen environment are 3 times more radiosensitive than cells in complete anoxia. It is the oxygen that reacts with the DNA damage and prevents its repair which ultimately leads to cellular death. Figure 21-3. Cell survival curves for differing mitotic stages showing the...

Pain

Pain is a common complaint among patients with cancer, especially patients with head and neck cancer. Pain can be acute, as a consequence of surgery, or chronic, as in shoulder disability secondary to accessory nerve sacrifice (Figure 23-2).52,53 Pfister and colleagues found a 31 percent prevalence of frequent or persistent pain in a cross-sectional analysis of 194 treated patients, 67 percent of which was moderate or great in intensity. Pain scores tend to improve with time in this population,...

Palatal Augmentation Prostheses

Patients who have undergone glossectomies with or without microvascular free-flap (radial forearm) reconstruction can improve consonant speech phonemes k,g and swallowing ability with the aid of a palatal augmentation (tongue) removable prosthesis (Figure 20-11). This can be considered when the remnant dorsum of the tongue (or reconstructed tongue with a flap) cannot make contact with the junction of the hard and soft palate. For optimal results, the patients will benefit with additional speech...

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...

Parotid Gland

Surgery is the treatment of choice for both primary and locally recurrent salivary gland tumors. Lumpec-tomy, enucleation or an excisional biopsy should not be performed because the recurrence rate is high even for benign lesions. The size and location of the mass would determine the extent of surgical resection with the goal of an adequate en bloc procedure.83 T1 and T2 lesions with a low-grade malignancy are approached with a superficial parotidectomy if the anatomic location and extent of...

Past Medical Surgical History

Previous gastrointestinal surgery is not a contraindication for reconstruction following laryngopharyn-goesophagectomy requiring gastric pull-up or free jejunal graft for reconstruction.44 Previous chemotherapy is not an absolute contraindication to medical therapy, but previous exposure to platinum compounds makes significant responses less likely. Repeat external irradiation or brachytherapy are poor options for patients who have received prior radiotherapy to the head and neck.

Posterior Pharyngeal Wall

This region is adjacent to the retropharyngeal space and is contiguous with the pharyngeal wall of the oropharynx with superior extension to the base of skull and inferiorly to the cervical esophagus. Primary tumors in this region are usually large and infiltrate deeply along the retropharyngeal space with lymph node metastasis in the retropharyngeal and cervical nodes. Because of the extent of most of these tumors at presentation, surgical resection is usually not possible. Radiation therapy...

Preface

Although oral cancer is the sixth most common cancer worldwide, cancer of the head and neck is a rare disease in the western world. A higher incidence is reported in Southeast Asia as well as certain parts of Europe and Latin America. Tobacco and alcohol remain the most important etiologic factors however, the primary site incidence of head and neck cancer varies throughout the world depending on the type of substance abuse and the extent of consumption. Management of these patients requires a...

Preoperative Radiation Therapy Indications

A major indication for preoperative radiation therapy is to improve the operability of a primary lesion or a fixed lymph node. A corollary indication is the initial use of a so-called test dose of radiation in a patient in whom full course radiation therapy is being seriously considered yet in whom there is concern with the tumor characteristics suggesting a less than optimal response. Strong8 reported on one of the first randomized trials in head and neck cancer which evaluated patients with...

Principles of Treatment

The extent of surgical resection for scalp tumors depends largely upon the depth of infiltration by the tumor. Excision through partial thickness of the scalp can be carried out for superficial tumors while excision through the entire thickness of the scalp including the periosteum may be necessary in deeply infiltrating tumors. On the other hand, tumors that are adherent to or involve the underlying cranium must have removal of the outer table of skull or a through-and-through resection up to...

Radiation Therapy

Conventional techniques have delivered radiation using external beam therapy, brachytherapy or a combination of both. More recent advances include altered fractionation schedules, radiation combined with chemotherapy or other sensitizers, and the use of accurately targeted beams with three-dimensional treatment planning or intensity-modulated radiotherapy. Important considerations in the delivery of radiation therapy include determination of adequate treatment volume (initial portals),...

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

Ridolfi RL, Lieberman PH, Erlandson RA, Moore OS. Schneiderian papillomas a clinicopathologic study of 30 cases. Am J Surg Pathol 1977 1 43-53. 2. Mashberg A. Erythroplasia the earliest sign of asymptomatic oral cancer. J Am Dent Assoc 1978 96 615-20. 3. Shafer WG, Waldron CA. Erythroplakia of the oral cavity. 4. Silverman S Jr, Gorsky M. Proliferative verrucous leuko plakias a follow-up of 54 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997 84 154-7. 5. Batsakis JG, Suarez P,...

Rehabilitation And Quality Of Life

Although appropriate reconstructive measures can minimize the effect on function, rehabilitation is often a prolonged and painstaking process that requires a great deal of patience. Successful reha bilitation depends on close multidisciplinary cooperation between the surgeon, the speech therapist, the prosthodontist, the dietitian, the nursing staff and the physiotherapist. Cessation of high-risk activity such as smoking and alcohol abuse must be emphasized. Quality of life and functional...

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 Tissue Reconstruction

Many patients that undergo mandible resection for cancer have significant soft-tissue involvement of the floor of mouth and the tongue by tumor. Resection of the intraoral mucosal lining can lead to scarring and immobility of the remaining portion of tongue, which can create significant functional problems. Recreation of an adequate buccal sulcus will allow use of dentures postoperatively, and will maintain space for placement of osseointegrated implants. Loss of soft tissue in the submental...

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...

Sphenoid Sinus

Early lesions with disease confined to the sphenoid sinus can be approached surgically through either a sub-labial or lateral rhinotomy approach. A cutting burr is then used to achieve a good exposure, which will allow dissection of the tumor. Disease extending into the surrounding anatomy sometimes can be resected using an infratemporal approach and a craniotomy. In both circumstances, postoperative radiation therapy within 6 weeks following the procedure will be necessary. Primary radiation...

Squamous Cell Carcinoma

Squamous cell carcinoma is the most common malignancy of the sinonasal tract. These tumors are more common in men than in women with a peak incidence between 60 to 70 years of age. There is an association between sinonasal squamous cell carcinoma and nickel exposure. Workers at a nickel refinery in Norway developed squamous cell carcinoma at 250 times the expected rate, with a latent period varying from 18 to 36 years.14 Although tobacco and alcohol are major risk factors for squamous cell...

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...

Surgery

The most common perioperative complications which may accompany surgical resection of sinonasal malignancies include intraoperative or postoperative bleeding, wound infection, cere-brospinal fluid leak, and visual or orbital injury if orbital preservation was planned. Visual complications including diplopia, lacrimal duct dysfunction, ectropion, and exposure keratopathy may occur in cases of maxillectomy with orbital preservation. Local morbidity from a maxillectomy defect depends on the extent...

Surgical Management of the Orbit

The specific indications for orbital preservation and exenteration have evolved over the past 40 years and remain a controversial subject. Although in the 1950s the orbit was almost routinely exenterated for any extension of maxillary sinus carcinoma toward the orbital floor, the emerging consensus is that the Table 11-1. SURGERY AND RADIATION THERAPY Table 11-1. SURGERY AND RADIATION THERAPY RT radiation therapy SCC squamous cell carcinoma. RT radiation therapy SCC squamous cell carcinoma....

Surgical Treatment

Successful outcome after surgery should provide the patient with durable locoregional control of the disease and minimal functional deficit. This depends on meticulous planning with accurate mapping of both surface and deep extent of the tumor. The anatomic extent of the surgical defect must be anticipated in all dimensions, and the need for reconstructive effort considered prior to surgery. The approach chosen must afford good exposure, both for accurate and complete resection of the lesion...

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...

Timing of Reconstruction

In the past, most mandibular reconstructions were delayed because of the inability to transfer tissue immediately. A rationalization for this approach included the idea that sufficient time should be allowed to get through the period for highest risk of local recurrence. This is now considered purely an excuse for inadequate reconstructive techniques. The idea that one should wait to see if the cancer recurs prior to performing the reconstruction is also invalid since contemporary techniques of...

Treatment

Schwannomas are most effectively treated by surgical excision however, these benign tumors of minimal malignant potential grow in a manner that usually, but not always, permits separation and preservation of their nerve of origin. Therefore, considerations of surgical morbidity should be included when selecting a treatment modality. Although clinical and radiographic information may suggest the diagnosis of a schwannoma, the precise nerve of origin may not be apparent until the tumor is...

Treatment Goals And Alternative Factors Affecting Choice Of Treatment

The treatment goals should be assessed individually for each patient prior to embarking on any course of therapy. These decisions should include careful consideration of many factors including (1) histology of the tumor, (2) tumor stage, (3) feasibility of a com plete surgical resection, (4) the patient's underlying medical condition, (5) associated treatment risks and morbidity, (6) reconstructive options for the restoration of form and function, (7) socioeconomic issues, (8) the surgeon's...

Tumor Factors

Complete surgical resection with an adequate margin of normal tissue forms the mainstay of treatment of mesenchymal head and neck tumors. The tight anatomic confines within the head and neck region dictate the extent of surgical excision and the same definitions of so-called adequate margins obviously cannot be held as relevant in head and neck tumors as for other locations. Adequate surgical excision of these tumors most often depends on the ability of the surgeon to do so without causing...

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...

Unknown Primary

No discussion of head and neck imaging would be complete without a discussion of the occult primary presumed to be within the upper aerodigestive tract. If one looks at the larger picture of patients with metastatic adenopathy above the clavicles, the role of imaging has increasing value. CT of the neck, chest, abdomen and pelvis usually follows the traditional method of panendoscopy and exam under anesthesia after an unproductive office exam. The advent of FDG-PET can obviate the need for such...

Vascularized Osteocutaneous Flaps

The development of microsurgery and further refinement of techniques in mandible reconstruction have revolutionized our ability to reconstruct the defect from a resected mandible. Since we can transfer large quantities of highly vascularized bone, soft tissue and skin with a single flap, almost any defect of the mandible can be reconstructed with one operation. Although vascularized tissue transfers are highly complex and time-consuming, their advantages far outweigh their disadvantages....

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...

Vertical Partial Laryngectomy

Cancers that arise on the true vocal cord with limited involvement of the anterior commissure (Figure 9-5) or arytenoid can be resected with a vertical partial laryngectomy. The majority of the ipsilateral thyroid cartilage, the true vocal cord, and portions of the subglottic mucosa and false vocal cord are removed (Figures 9-6 to 9-8). The strap muscles are closed over the defect and can be used to form a pseudocord. A tracheotomy is generally left in place for 3 to 7 days. Anterior commissure...

Pathology

Noninvasive imaging can reliably diagnose some soft-tissue lesions such as lipomas, benign vascular tumors, and fibromatosis. For most other tumors, histologic examination of a biopsy specimen is currently the only reliable technique that can lead to a definitive diagnosis. Several techniques are in common use fine-needle aspiration (FNA), core needle biopsy, incisional biopsy and excisional biopsy. FNA is the easiest to perform and can be safely undertaken at the first clinic visit of a...

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...