Head and Neck Cancer
Manhattan Maxillofacial Surgery NY
Head and Neck Cancer is most typically squamous cell carcinoma. This type of cancer arises from the surface lining of the mouth, throat, or other areas just as it can arise from the surface of the skin or other parts of the body. It is one of the most common types of cancer to occur in the head and neck area. If this disease were to go on untreated, the tumor would grow at a fairly slow rate until it attains a certain size at which time it would shed off tiny cells that would attempt to spread to other parts of the body. This process is called metastasis and it is this characteristic that differentiates a malignant cancer from a benign tumor. Other types of cancer include salivary gland and sarcoma. Dr. Hirsch offers services for all Head and Neck Cancer.
THE LYMPHATIC SYSTEM
In the head and neck area, like other parts of the body afflicted by cancer, squamous cell carcinoma tends to spread through the lymphatic system. The lymphatic system is a series of tubes that carry a body fluid called lymph. In a sense, this system is much like our system of blood vessels; however, the lymph vessels are much, much smaller and the lymphatic fluid is colorless. Another very important difference between the lymph system and the system that carries blood is that the lymph system contains a series of filters called lymph nodes or lymph glands. These lymph nodes serve as filters; much like an automobile or truck engine has oil filter to filter out impurities in the oil. The head and neck area contains many more lymph nodes than other body parts and in fact, of the 700 or so lymph nodes contained within the human body, half are located above the collar bones. What this means is that the lymph nodes in the head and neck area are much more efficient as filters than they are in other parts of the body. It is only very late in the progression of a head and neck squamous cell carcinoma that the cancer spreads beyond these lymph nodes in the neck to involve other areas such as the lung or liver.
In some patients, the swollen and usually painless lymph node that is filtering cancer cells is the first sign that alerts the patient that something is going on that needs to be checked by a doctor. The primary site of origin of the cancer may be unknown (“unknown primary“) and the head and neck surgeon must become a medical detective to try to find the hidden primary cancer. In some situations, the hidden primary can be found, but in others, the primary site where the cancer started may remain a mystery.
THE INFORMATION GATHERING PROCESS
Before we plan treatment of your cancer, we must obtain accurate information upon which we will base our choices and decisions. The biopsy has provided the information as to the identity of the type of cancer squamous cell carcinoma. A CT scan (computerized tomography, also called a CAT scan) or an MRI (magnetic resonance imaging) will give us a 3-dimensional view of the tumor and the anatomy adjacent to it. The scans can also help us see if any of the lymph nodes in the neck are enlarged, which may signify that they are in the process of filtering out cancer cells. Some patients will also require a panendoscopy which is a detailed visual examination of the throat, voice box and swallowing passage done under general anesthesia. Additional testing includes routine blood work and a chest X-ray. Unfortunately, there is no reliable single test that will determine if the cancer has spread to other body parts, although the chance of that is very, very low in early head and neck cancer.
TREATMENT PLANNING AND OPTIONS
In considering the options for treatment, we consider your problem in two parts, the first being the problem of the primary site where the cancer started and the second being the possibility that there are or may be cancer cells within the lymph node filters in the neck. Our treatment plan must be designed to treat both the primary cancer at its starting point and also to treat any malignant cells that are in the lymph nodes in the neck. Sometimes the treatment for each of these areas may differ. The treatment of squamous cell carcinoma in the head and neck area is like cancer treatment anywhere else in the body in that we have three general categories of treatment available. Despite what you might read in the Sunday newspaper about new cancer “breakthroughs”, treatment tends to fall within one of these three categories:
Oral Cancer Case Study
4 months following resection and reconstruction using vasularized forearm skin and radial bone.
Chemotherapy consists of a course of intravenous medication that is given by a specialist in medical oncology. In the United States, medical oncologists are referred to as “oncologists”. In other malignant diseases such as leukemia, chemotherapy has made tremendous strides and now leukemia is frequently curable with chemotherapy alone. Regarding squamous cell carcinoma of the head and neck, chemotherapy is of more limited usefulness. In some patients, it is helpful in reducing the size of a tumor which can allow subsequent therapy such as surgery or radiation to be more effective. Chemotherapy is usually given in a series of two or three treatment cycles separated by recovery periods of three or four weeks. The medical oncologist administers the chemotherapy either on an inpatient or outpatient basis. Side effects include a temporary feeling of illness or nausea as well as temporary hair thinning or loss.
2. RADIATION THERAPY
Radiation therapy is given by a specialist called a radiation oncologist and is given at a radiation center, which is often affiliated with a hospital. The treatments are brief, are given every day Monday through Friday, and the total course of therapy usually lasts from six to seven weeks. Radiation therapy is a beam of energy which is somewhat like a beam of light except that radiation therapy beams go right through body tissues and do not cast a shadow. The radiation therapy beam injures all body tissues contained within the precise area within which the beam is focused. This injury is a lethal one to the cancer cells and is an injury that the normal tissues recover from, with some side effects. Radiation therapy is very useful for small tumors and what it does best is wipe out small bits of cancer.
When a cancer is larger or when it is close to bone, radiation therapy is less useful as a single means of treatment. More commonly, radiation therapy is combined with chemotherapy or surgery like a 1 – 2 punch to produce a greater response. The most common side effects of radiation therapy in the head and neck are related to a relative drying of saliva and alteration in taste. This reduction in the amount of saliva requires meticulous daily tooth brushing and flossing, and daily application of fluoride to the teeth, for life. Radiation therapy also tends to temporarily drain one’s energy and patients commonly observe that they feel fine during the early part of treatment only to be quite tired at the end of the six to seven weeks. The energy slowly returns.
Surgery at the primary site seeks to remove the primary cancer with a three-dimensional rim of uninvolved tissue surrounding it. Surgery for the lymph nodes in the neck involves removing these lymph nodes through an operation called a neck dissection. Another role of surgery at the primary site is to reconstruct the defect created by removal of the cancer. A number of reconstructive techniques are used sometimes using regional tissues and sometimes importing body tissues from such places as the skin of the wrist and one of the bones of the lower leg to reconstruct mouth, jaw and facial parts. Surgery for squamous cell carcinoma of the head and neck may require a tracheotomy, which is a temporary breathing tube placed into the windpipe in the neck. The tracheotomy tube is almost always removed before discharge from the hospital. Side effects of surgery involve some limitation of function of the involved structures, regional numbness and possible deformity. Following a neck dissection, some patients will experience a loss of function of the trapezius muscle that produces a painful shoulder condition that is almost always temporary, but may be permanent.
It has been determined that of the three ways to treat cancer, no one way is generally superior to the others and commonly the three techniques are combined in some manner to produce the best results. Chemotherapy and radiation therapy are often given simultaneously “chemoradiotherapy” for enhanced tumor-killing effect. In other situations where chemotherapy is not of benefit, surgery is often followed by radiation therapy.
It is well-known that radiation therapy and bad teeth do not mix. The reason for this is that radiation therapy reduces the local blood supply to the radiated tissues and thus decreases the ability of irradiated tissues to heal. Any injury or surgery, such as tooth extraction, that might follow radiation therapy can result in an extremely painful wound that will not heal without extraordinarily complex and costly therapy. This effect is particularly true in the lower jaw and even a minor dental infection or gum boil that occurs after radiation therapy can produce a major infection that is very difficult to treat. We have learned that bad or even questionable teeth need to be removed before radiation therapy begins and that good teeth need to be critically evaluated by your dentist before radiation starts. When good teeth are preserved through radiation therapy, the patient must practice excellent oral hygiene including proper brushing and flossing, for life. Custom-made carriers are used for the daily application of fluoride to the teeth, for life. The side effects of radiation therapy don’t get better over time, they stay the same or get worse.
Nutrition is a critical part of every head and neck cancer patient’s care. All aspects of cancer treatment greatly increase the patient’s daily caloric requirement and this occurs at a time when eating is difficult because the mouth is sore from therapy or healing from surgery. Years ago, head and neck cancer patients used to lose huge amounts of weight as they went through treatment, weakening them and also making their cancer treatment more difficult. Tube feeding by means of a tube placed through the nose and down to the stomach helps and is still sometimes used, but it is difficult to keep a nasal tube in place for three or four months. We now utilize a PEG tube (percutaneous endoscopic gastrostomy) feeding tube that is placed through the abdominal wall with a technique that does not require an actual open operation. The tube provides a lifeline for nutrition and medication when the mouth and throat are sore from treatment. It can be taped up to the tummy wall, out of the way when not in use. The PEG tube is usually in place for three or four months and does not interfere with normal eating by mouth. When the patient no longer needs the PEG tube and is maintaining weight by eating exclusively by mouth, the tube is simply pulled out and the hole closes by itself. Like any medical procedure, there can be complications with the PEG tube, but they are uncommon.
After the cancer therapy is completed, a structured follow-up program is necessary to periodically re-evaluate you to check for recurrence of the cancer or the possible development of a new head and neck cancer. These appointments are usually scheduled every few months during the first year and the interval between appointments increases during the second year. We can often alternate appointments with your local doctor to minimize the number of trips you have to make to New York. After five years, most head and neck cancer patients are discharged, with instructions to call or return if problems develop.