SURGICAL MANAGEMENT OF HEAD AND NECK CANCER

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Surgery has been the mainstay of therapy for head and neck cancer since the introduction of the radical neck dissection by Crile at the turn of the century. To date, with the notable exception of nasopharyngeal carcinoma, surgical resection remains the gold standard for treatment of head and neck cancer. As chemotherapy has developed over the last 15 years, nonsurgical modalities have been increasingly used in initial as well as salvage therapy. Head and neck surgery, however, is a quickly developing field. Even as multicenter national trials document the possibility of nonsurgical organ preservation, surgical techniques are being pioneered that may offer dramatically improved chances for organ preservation compared with that achieved by chemotherapy and radiation. Innovative surgical resection and reconstruction techniques have been developed for head and neck cancer surgery during the past few years. This article summarizes the state of the art in head and neck cancer surgery. For each major subsite of the head and neck, the current surgical options are presented with discussion of the indications and expected outcomes. This article presenting the management of head and neck cancer from the surgeon's perspective can serve as a surgical guide for the medical oncologist interested in head and neck cancer.

Section snippets

Indications for Surgery

A variety of tumor types, both benign and malignant, occur in the nose and sinuses. This discussion is restricted to malignant tumors. The most common malignant tumor of the sinonasal region is squamous cell carcinoma, usually presenting in the maxillary sinus. Adenocarcinoma, esthesioneuroblastoma, melanoma, and lymphoma are, however, all seen in a much higher percentage of cases in the nose and sinuses than in other anatomical subsites of the upper aerodigestive tract.1, 64, 133 For nearly

Indications for Surgery

Oral cavity carcinoma includes lesions of the labial and buccal mucosa, alveolar ridges, retromolar trigone, hard palate, floor of mouth, and anterior two thirds of the tongue. Cancers in this location have a high propensity for early spread to cervical lymphatics, including bilateral involvement. Oral cavity cancers are often close to the mandible and involve the tongue. This relationship requires each case to be carefully considered in terms of the effect of the treatment on the mandible and

Indications

Oropharyngeal cancers are divided into several subsites, including the soft palate, tonsil, tongue base, and posterior pharyngeal wall. The decision to offer surgery for oropharyngeal tumors depends on the subsite and stage of the tumor. Surgery for T1 and T2 tumors of the palate, posterior pharyngeal wall, and tongue base is associated with significant morbidity. Wide local excision of these tumors with 2- to 3-cm margins creates a significant defect in functionally critical tissues. In

Indications

As with most head and neck tumor sites, the hypopharynx has traditionally been treated with surgery followed by radiation therapy. The exceptions are the early stage tumors of the hypopharynx. Early cancers of the hypopharynx are rare, but when they are diagnosed, treatment is generally with external beam radiation therapy.57, 88 Partial pharyngectomy may be possible if the tumor is limited to the lateral pharyngeal wall. If so, limited resection can be performed with primary closure. Even for

Indications

Perhaps the greatest innovation and continued advance in head and neck surgery has been in oncologic surgery of the larynx. Beginning in the early 1960s, a series of options has emerged that make many patients candidates for partial laryngeal surgery. Historically, as an alternative to radiation therapy, the surgeon had two options: total laryngectomy or laryngofissure with cordectomy. Because of the morbidity of the cordectomy procedure and the high degree of success with radiation therapy, it

NECK METASTASES

Cervical lymph node metastases from head and neck squamous cell carcinoma remain an ominous prognostic factor. For most patients, the presence of any neck metastasis will reduce the cure rate by about 50%. In patients with neck metastases, extracapsular spread remains the worst prognostic finding on pathologic examination, correlating with both recurrence in the neck and with distant metastasis.

The management of all but the earliest confirmed neck metastases is best achieved with surgical

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    Address reprint requests to Steven C. Marks, MD, Department of Otolaryngology, Grace Hospital, 6071 West Outer Drive, Detroit, MI 48235

    *

    Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan

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    Copyright © 1999 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.