Surgery for Head and Neck Cancers: Head and neck cancers are currently the most common cancers to occur in men and the third most common cancers in women after breast and gynaecological cancers. The main reason for sudden rise in head and neck cancers is the recent increase in tobacco and alcohol consumption in our society especially in the young population. The most common cancers in this region include oral and throat cancers, thyroid cancerr, salivary gland cancers and skull base cancers.
Oral cancers mostly present as ulcers or growths in the mouth, over the tongue, gums, the inside of cheek and the throat. The most common sites are the cheek and gingivobuccal sulcus in men and tongue in women. Most of these oral cancers are related to habitual tobacco chewing and smoking. Other causes include chronic injury by sharp teeth and faulty dentures and HPV infection.
The earliest signs include non healing ulcers in the mouth, loosening of teeth, any lumps or bumps in the gums, bleeding gums, neck swelling and any change in voice or difficulty in swallowing food. Diagnosis is confirmed by biopsy, i.e. a small piece of tumor is taken and subjected to pathological examination in the laboratory. Other investigations include CT scan and MRI of face and neck to assess local extent of disease and plan of treatment.
Surgery remains the mainstay of treatment. In most situations the treatment of oral cancer is surgical removal of tumor with a margin of surrounding tissues and removal of lymph glands in the neck. This may a commando operation or oral composite resection along with segmental or marginal mandibulectomy and maxillectomy for cancers of cheek and gums. The surgery for cancer of tongue includes either partial or hemi-glossectomy according to the site and size of lesion. This is followed by reconstruction of the defect using any local or distant tissues around the head and neck region depending on the size and location of defect. Nowadays with the development of newer surgical and reconstructive techniques such as microvascular flaps we can achieve good cosmesis and better functional outcomes in terms of swallowing and speech in most patients. Some patients also need radiotherapy and or chemotherapy to prevent any recurrence of disease.
Thyroid cancers are classified as well differentiated carcinomas (papillary & follicular), medullary carcinoma and poorly differentiated anaplastic cancers. Papillary cancers usually occur at a younger age as compared to anaplastic cancers. Thyroid cancers present with symptomatic nodules or swellings in the front of neck. Sometimes they may be diagnosed as incidentally detected thyroid nodules on imaging done for other ailments. Diagnosis is confirmed with ultrasonography and guided FNA from suspicious thyroid nodules.
The treatment of well differentiated thyroid carcinomas is total thyroidectomy with cervical lymph node dissection. There is no role of conventional chemo-radiotherapy in these cancers. Postoperatively some patients may need radio-iodine scan and ablation of any active lesion after 3-4 weeks of surgery.
Medullary thyroid carcinomas are uncommon as compared to papillary cancers. The treatment involves total thyroidectomy and bilateral cervical lymph node dissection followed by radiation therapy. Anaplastic thyroid cancers usually occur in elderly individuals and are rare and aggressive tumors. Most patient may be inoperable at presentation and have very poor outcomes.
Cancers of larynx or throat presents with hoarseness or change in voice, breathing difficulty and difficulty in swallowing in late cases. More than ninety percent of these cancers are related to consumption of alcohol or smoking. Diagnosis is established by endoscopic evaluation of voice box and throat (Laryngoscopy) with biopsy of any suspicious growths or ulcers. Most patients with initial stage at presentation can be cured with radical radiotherapy and chemotherapy. Selected patients may be treated with laser surgery which involves complete excision of vocal cord lesions preserving the voice box with normal speech. Unfortunately most patients in India present in advanced stages and need surgery (Total/Partial Laryngectomy). Contrary to belief, patients who have undergone removal of their voice box for cancer can speak well with good phonation with TEP (tracheoesophageal prosthesis). During laryngectomy this voice prosthesis is placed in the throat between trachea and esophagus; which allows normal and intelligible hands free speech. Selected patients may require radiotherapy and chemotherapy in addition to laryngectomy to prevent any recurrence of disease. Modern surgical techniques and improvement is precision radiation techniques allows for preservation of larynx in some patients and excellent functional outcomes and voice preservation in patients undergoing total laryngectomy.
Dr Ashish Goel Director Surgical Oncology is an expert for Surgery for Head and Neck Cancers. He and his team regularly perform oral resections and reconstruction with microvascular free flaps.