Published in UAB Insight, Spring 2008
ABSTRACT: Less invasive techniques have improved morbidity for treatment of head and neck malignancies and resulted in better postsurgical function and cosmesis.
CME OBJECTIVE: Readers will be aware of new approaches for head and neck cancer.
Glenn E. Peters, MD, no conflicts of interest; William R. Carroll, MD, no conflicts of interest; Paul F. Castellanos, MD, no conflicts of interest; Eben L. Rosenthal, MD, no conflicts of interest
During the last 2 decades surgeons have enhanced postoperative function and cosmesis in patients with head and neck cancer while maintaining good survival rates.
The improvements have come on multiple fronts, says Glenn E. Peters, MD, director of the UAB Division of Otolaryn-gology — Head and Neck Surgery. “We are using microvascular free flaps, minimally invasive procedures, transoral robot-assisted surgery, and advanced organ conservation techniques to attain improved morbidity rates — often with shorter hospital stays and quicker recovery times.”
UAB head and neck cancer surgeons are among the busiest in the nation, operating on patients from around the Southeast. The time and manpower required for major surgeries, particularly free-flap reconstruction, are difficult for smaller practices, Peters says.
With changing paradigms, most head and neck endocrine surgery is now performed on an outpatient basis at UAB. “Endoscopic techniques with video assistance have led to less down time and morbidity,” he says. “The techniques for thyroid and parathyroid surgery require an incision of just 2.5 to 3 cm.”
Bilateral neck exploration is no longer routinely performed at the time of parathyroidectomy, Peters says, so preoperative localization of parathyroid adenomas is increasingly important. “Successful preoperative localization with ultrasound imaging, Tc99m-sestamibi scans, and intraoperative parathyroid hormone assays provides an acceptable, if not desirable, alternative,” he says (Arch Otolaryngol Head Neck Surg. 2007;133[12]:1240-1244). Ultrasonography also is useful for the diagnosis of concomitant thyroid disease.
A multi-institutional study recently concluded that the safety of minimally invasive video-assisted thyroidectomy technique supports its expanded adoption by high-volume thyroid surgeons (Arch Otolaryngol Head Neck Surg. 2008;134[1]:81-84).
Robot-assisted Surgery
UAB head and neck oncologic surgeon William R. Carroll, MD, was the first in the South to use the da Vinci surgical robot to treat pharyngeal and tongue-base tumors. He and colleague J. Scott Magnuson, MD, give UAB one of the highest operating volumes in the nation for robot-assisted surgery. “The robot allows us to spare patients the ear-to-ear incisions that often require splitting the lip and jaw to gain access to a malignancy,” he says.
Transoral robotic surgery allows for complete tumor removal while helping preserve voice and swallowing function. “The three-dimensional stereoscopic view of the operative site, along with the dexterity and flexibility of the wristed instruments, contribute to the utility of the device. As instrumentation improves for these small spaces, even more structures will be evaluated for this modality,” Carroll says.
The concept behind robot-assisted surgery is complete tumor removal via a minimally invasive approach using natural orifices. “We are still early in our experience with this approach but believe it has potential for improved quality of life, shortened length of stay and recovery, and fewer side effects,” he says.
Transoral Laser Microsurgery
Transoral laser microsurgery allows surgeons to assess margins in multiple planes and microscopically map tumor depth, assuring minimum loss of healthy tissue, fewer surgical contraindications, and avoidance of tracheostomies and extensive reconstruction. In patients with advanced laryngeal cancer, TOLMS with or without radiotherapy is a valid treatment strategy for organ preservation. Furthermore, low morbidity and mortality and excellent oncologic and functional outcomes make TOLMS an attractive therapeutic option (Arch Otolaryngol Head Neck Surg. 2007;133[12]:1198-1204).
Paul F. Castellanos, MD, who directs UAB’s Voice and AeroDigestive Center, says TOLMS allows surgeons to remove even selected T4 pharyngeal tumors transorally and tailor surgical margins to the tumor, often excising significantly less normal tissue than with open surgery. “Tumors of the oral cavity, including those of the tongue, floor of mouth, buccal mucosa, and the hard and soft palates, are potential candidates for this kind of care,” Castellanos says.
“Tumors of the pharynx and larynx also are common areas amenable to this technique. This surgery is challenging and should be performed only by experienced surgeons who have additional training beyond the normal residency in otolaryngology,” he says.
Reconstructive Surgery
Head and neck cancer surgery often results in large tissue defects associated with devastating functional deficits and disfiguring deformities. Radiation therapy to the area often impairs healing mechanisms leading to wound breakdown and fistula formation (Cur Cancer Ther Rev. 2006;2[1]:67-72).
“Advancement in reconstructive techniques allows ablative surgeons greater latitude in resecting deeply invasive lesions, especially in heavily pretreated cases,” says head and neck surgeon Eben L. Rosenthal, MD. The surgical defect often is complicated by the presence of large cutaneous, dural, or aerodigestive tract defects. Reconstructive goals include promoting wound healing, protecting the carotid arteries and internal jugular veins, restoring function, and reconstructing facial contours.
Reconstruction falls into three major categories:
- Large defects of the sinuses, tongue, mouth, or throat;
- Loss of significant skin, usually involving tissues of the eye socket or skull base; and
- Secondary problems related to surgery such as saliva leakage (fistula) or postradiation necrotic bone.
Free-flap tissue transfer surgery is one of the most dramatic developments in the field of head and neck surgery, contributing to reconstruction of the entire lower jaw, throat, palate, tongue, and other parts.
Free flaps were first introduced for head and neck reconstruction in 1974, and sensate radial forearm free flaps for oral cavity reconstruction were championed in 1990. Rosenthal, whose annual caseload of 150 major head and neck reconstructions may be the highest in the country, says use of the anterolateral thigh (ALT) as a donor site for the free flap is increasingly favored in selected cases. “It is appropriate for reconstruction of certain defects of the lateral temporal bone and others based on a classification system developed to help predict reconstructive options,” Rosenthal says.
“The radial forearm free flap remains the workhorse of reconstruction, but the volume of tissue is limited,” he says. “Myocutaneous flaps such as the rectus abdominis and latissimus dorsi supply more tissue but are often bulkier. The ALT flap provides bulk that is midway between the two and can be thinned in subsequent procedures to the desired thickness.”
Free-flap microsurgery has evolved over the past 3 decades from 24-hour heroic operations to routine 4- to 6-hour procedures that see patients alert and ambulatory on postsurgical day 1 and discharged from the hospital by day 6 or 7 (Head Neck. 2004;26[11]:930-936).
Most patients are candidates for reconstruction, from a 90-year-old woman to an immunosuppressed transplant patient. Almost all go directly to a stepdown intensive care unit. Vascular insufficiency occurs in about 5% of cases, most of which are salvageable.
Rosenthal, who is certified as a facial plastic surgeon, attributes his large reconstructive practice to the success of the head and neck oncology team as a whole. “We have a smoothly functioning team that works in concert to review cases that need combined treatment. Our weekly tumor board includes oncologists, dentists, radiation therapists, surgeons, and pathologists. Our success is derived from the team approach and the talents that each specialty brings to the table.”
For more information:
Dr. Glenn Peters
Dr. William Carroll
Dr. Paul Castellanos
Dr. Eben Rosenthal
1.800.UAB.MIST
mist@uabmc.edu