Professional Documents
Culture Documents
MALIGNANCIES
CONSULTING EDITOR
NICHOLAS J. PETRELLI, MD, Medical Director, Helen F. Graham Cancer Center,
Newark, Delaware; and Professor of Surgery, Jefferson Medical College, Philadelphia,
Pennsylvania
GUEST EDITOR
WESLEY L. HICKS, JR, DDS, MD, FACS, Attending Surgeon, Department of Head and
Neck Surgery, Roswell Park Cancer Institute; Associate Professor of Otolaryngology,
Head and Neck Surgery, and Neurosurgery, School of Medicine and Biomedical
Sciences, State University of New York at Buffalo, Buffalo, New York; and Director,
Head and Neck Surgical Fellowship Program, Roswell Park Cancer Institute
CONTRIBUTORS
RONALD A. ALBERICO, MD, Associate Professor of Radiology, Assistant Clinical
Professor of Neurosurgery, School of Medicine and Biomedical Sciences, State
University of New York at Buffalo; Director of Neuroradiology/Head and Neck
Imaging, Department of Radiology, Roswell Park Cancer Institute, Buffalo, New York;
and Acting Director of Pediatric Neuroradiology, Buffalo Children’s Hospital, Buffalo,
New York
WADE DOUGLAS, MD, Fellow, Department of Head and Neck Surgery, Roswell Park
Cancer Institute, Buffalo, New York
KEVIN J. GIBBONS, MD, Program Director and Director of Skull Base Surgery,
Department of Neurological Surgery, School of Medicine and Biomedical Sciences,
State University of New York at Buffalo, Buffalo, New York
iii
RALPH W. GILBERT, MD, FRCSC, Associate Professor, Head and Neck Surgical
Oncology; Reconstructive Microsurgery, University Health Network; Princess
Margaret Hospital; and Department of Otolaryngology, University of Toronto,
Toronto, Canada
SYED HAMED S. HUSAIN, DO, Radiology Resident, School of Medicine and Biomedical
Sciences, State University of New York at Buffalo, Buffalo, New York
JEFFREY N. MYERS, MD, PhD, Associate Professor of Head and Neck Surgery,
Department of Head and Neck Surgery, The University of Texas M.D. Anderson
Cancer Center, Houston, Texas
RYAN F. OSBORNE, MD, Director, Head and Neck Oncology, Cedars-Sinai Medical
Center; and Assistant Professor, Department of Otolarynology–Head and Neck
Surgery, Charles R. Drew University of Medicine and Science, Los Angeles, California
CARSTEN E. PALME, MB BS, FRACS, Clinical Fellow, Oncologic Head and Neck
Surgery, Department of Otolaryngology, University of Toronto, Toronto, Canada
JAMES REIDY, DO, Fellow, Department of Head and Neck Surgery, Roswell Park Cancer
Institute, Buffalo, New York
iv CONTRIBUTORS
IGOR SIROTKIN, MD, Radiology Resident, School of Medicine and Biomedical Sciences,
State University of New York at Buffalo, Buffalo, New York
KEITH WILSON, MD, Associate Professor, ENT/Head and Neck Surgery, University
of Cincinnati, Cincinnati, Ohio
MAHER N. YOUNES, MD, Postdoctoral Fellow, Department of Head and Neck Surgery,
University of Texas M. D. Anderson Cancer Center, Houston, Texas
CONTRIBUTORS v
FORTHCOMING ISSUES
April 2004
Multidisciplinary Approach to
Anal Cancer
Morton S. Kahlenberg, MD, and
Charles R. Thomas, Jr, MD, Guest Editors
July 2004
Palliative Care
Lawrence D. Wagman, MD,
Guest Editor
October 2004
Adjuvant Therapy of Pancreatic
Adenocarcinoma
John P. Hoffman, MD, Guest Editor
RECENT ISSUES
October 2003
Intraoperative Radiotherapy
Hollis W. Merrick, MD, and
Charles R. Thomas, Jr, MD, Guest Editors
July 2003
Management of Peritoneal Surface
Malignancy
Paul H. Sugarbaker, MD, FACS, FRCS,
Guest Editor
April 2003
Emerging Perspectives in
Soft Tissue Sarcoma
Raphael E. Pollack, MD, PhD
Guest Editor
Foreword
Nicholas J. Petrelli, MD
Consulting Editor
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.soc.2003.12.010
xiv N.J. Petrelli / Surg Oncol Clin N Am 13 (2004) xiii–xiv
Nicholas J. Petrelli, MD
Consulting Editor
Helen F. Graham Cancer Center
4701 Ogletown-Stanton Road
Suite 1212
Newark, Delaware 19713, USA
Jefferson Medical College
Philadelphia, Pennsylvania
Surg Oncol Clin N Am
13 (2004) xv–xvi
Preface
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.soc.2003.12.009
xvi W.L. Hicks / Surg Oncol Clin N Am 13 (2004) xv–xvi
1
Current address: Department of Surgery, St. Paul’s Hospital, 1081 Burrard Street,
Vancouver, British Columbia, Canada, V6Z 1Y6.
* Corresponding author.
E-mail address: garth.anderson@roswellpark.org (G.R. Anderson).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00118-2
2 S.M. Wiseman et al / Surg Oncol Clin N Am 13 (2004) 1–11
Many patients with head and neck cancer are cancer predisposed
HNSCC arises from a complex interaction between the host (genetic
factors) and the environment. Tobacco exposure has long been recognized
as increasing the risk of developing HNSCC between 2- and 20-fold [12].
More than 50 years ago, Slaughter et al [13] recognized the ‘‘field can-
cerization’’ that occurs in patients with HNSCC as a consequence of pro-
longed carcinogenic exposure of the upper aerodigestive tract. It is this
‘‘field cancerization’’ that is believed to be responsible for the 2% yearly
incidence of second primary tumors that develop in this patient population.
Furthermore, the concurrent consumption of alcohol with tobacco may
have a multiplicative effect on the risk of developing HNSCC [14–16]. In
addition to tobacco and alcohol exposure, other environmental factors that
are currently believed to play a role in HNSCC development include viruses,
radiation exposure, and certain nutritional deficiencies [17–19].
Epidemiologic and experimental evidence suggests that, because of an
inherent inability to maintain their genomic integrity in the presence of specific
environmental stressors, certain individuals demonstrate a predisposition to
developing head and neck tumors. The occurrence of this malignancy, even in
the absence of environmental carcinogen exposure, supports this concept. The
current authors recently described a cohort of 40 nonsmoking, nondrinking
patients with HNSCC treated at Roswell Park Cancer Institute. These
patients tended to be elderly (median age, 60 y), female, and white. In addition,
they had oral cavity primary tumors and were predisposed to second primary
tumor development. Despite a lack of exposure to tobacco and alcohol, 10
patients (25% of study population) eventually developed a second primary
tumor. The occurrence of second primary tumors in this patient population
suggests a possible genetic pre11disposition of these individuals to HNSCC
S.M. Wiseman et al / Surg Oncol Clin N Am 13 (2004) 1–11 3
Summary
Measurements of genomic instability, or identification of genes respon-
sible for instability, may potentially be used as molecular markers to predict
disease course and response to therapy. Other possible applications include
use of genomic instability measurements, or genes, as tools to screen for
primary or recurrent disease. Methodologies for detection of genetic
mutations in saliva, blood, and sputum have already been described
[61,62]. Brennan et al [63] have described a molecular technique for
analyzing histopathologically negative margins and lymph nodes for the
presence of p53 gene mutation. This study showed that a positive molecular
margin significantly predicted disease recurrence.
The recognition that HNSCC is a genetically heterogeneous disease repre-
sents a major step toward developing an understanding of its underlying
genetic basis. To develop an insight into this genetically heterogeneous
disease, investigators must not only focus their efforts on specific head and
neck disease sites. Laser-capture microdissection represents a powerful tool
for isolating very specific cell populations from tumors [64]. Leethanakul et al
[65] performed laser-capture microdissection on oral cavity SCC to construct
stage-specific cDNA libraries. Sequencing of 96 clones from each of the six
libraries constructed suggested the existence of 132 novel genes, which may
play a role in the pathogenesis of HNSCC.
The current literature suggests that many individuals diagnosed with
HNSCC are genetically predisposed to developing malignancy because of
some inherent deficiency of their capacity to maintain their genome in the
presence of environmental stressors. Head and neck cancers are highly het-
erogeneous tumors and exhibit a wide variety of forms of genomic
instability. Thus, genomic instability may be viewed as a fundamental force
driving head and neck tumorigenesis and evolution. Future study of the
specific genetic mechanisms that underlie genomic instability in the HNSCC
patient population is needed. It is only through study of this fundamental
force that drives the development of these tumors that clinicians may gain
the insight required to develop new diagnostic and therapeutic modalities to
benefit the HNSCC patient population as a whole.
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Surg Oncol Clin N Am 13 (2004) 13–35
* Corresponding author.
E-mail address: ronald.alberico@roswellpark.org (R.A. Alberico).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00124-8
14 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
and neck cancer in a manner that maximizes the clinician’s ability to make
appropriate treatment plans and avoid unnecessary complications.
The primary goal in imaging of head and neck oncology is to answer the
pertinent clinical questions. Too often, the radiologist can get caught up in
the collateral findings and provide information that is confusing or
superfluous while omitting key points needed for the treatment plan.
Although the clinician may feel comfortable filling in the blanks, the scan
may not be optimally designed to answer the clinical question, particularly
in postoperative patients. Frequently, the radiology requests provide
insufficient clinical information to adequately plan the scan, possibly
resulting in exclusion of anatomy crucial to the diagnosis. The solution to
these problems is knowledge and communication. The radiologist must be
familiar with the surgical procedures available and the anatomic criteria that
exclude various procedures from consideration. In addition, the radiologist
must be made aware of the clinical findings and concerns to select the
appropriate imaging modality and optimize the imaging technique. The
radiologist’s goal should be not only to answer the questions of size and
extent of tumor but to point out potential surgical complications resulting
from vascular relationships to the tumor, and individual anatomic variants
that may complicate the procedure. The formation of a differential diagnosis
based on lesion location and imaging characteristics plays an important, but
secondary, role in this process. Even with the best modern imaging
available, the radiologist is still relegated to the role of gross pathologist,
with some limited physiologic data, and, as always, the final answer is in the
histology.
Imaging techniques
The radiology and head/neck surgery literature over the last decade has
supported either CT or MRI as the primary technique for evaluating
patients who have head and neck cancer. This situation has divided the
radiology community into two groups, each of which feels passionately
about their respective choices. CT has been shown to be superior to MRI in
evaluating necrosis in nodal metastases [6], whereas MRI is better for
detecting perineural extent of disease and disease at the skull base [5,7,8].
Other authors have shown improved lymph node detection with MRI [3].
Both modalities have advantages and disadvantages in the evaluation of
head and neck cancer. CT has the advantage of increased speed and
availability and better patient tolerance. The bony framework is better
evaluated with CT and small calcifications are more apparent. CT has the
disadvantage of requiring ionizing radiation and iodinated contrast agents.
MRI is more sensitive for subtle spread of disease along nerves and into the
skull base. In addition, MRI has higher soft tissue contrast resolution and
direct multiplanar imaging capability. Disadvantages of MRI include lower
patient tolerance and dangers associated with metallic implants, pacemakers
R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35 15
and other hardware, and increased expense. MRI is also subject to many
artifacts that can make interpretation more difficult. Patient motion is
always a concern in MRI, particularly in patients who have difficulty
suspending swallowing and lying flat.
PET scanning and ultrasound take a definite back seat to CT and MRI in
evaluating the head and neck. Ultrasound is useful for image-guided biopsy
and can provide the fastest, easiest means to guide the needle to the
appropriate target. Doppler sonography has shown some ability to improve
the specificity and sensitivity of nodal staging in clinically N0 neck disease,
as has PET imaging, but the clinical criteria for exploring N0 neck disease
frequently obviates the need to use PET or ultrasound for this purpose [9].
The current authors have found that, for most patients, CT, when
properly performed, provides a readily available and easily tolerated
assessment of head and neck neoplasia. It is easier to interpret for nodal
staging and successfully completed more often than MRI. Multidetector CT
obtained with thin images (2.5 mm) and contrast is able to detect
perineural disease and is readily reformatted into multiple imaging planes.
The current authors typically assess patients initially with CT and will
obtain MRI only if perineural spread of disease is suspected or ambiguous
on CT, or to better evaluate cartilage or marrow invasion. MRI is also
useful in patients who have tumors that are typically lower in attenuation on
CT, such as liposarcomas, and may provide additional information in
patients with this type of tumor. The current authors also use MRI for
thyroid tumors that may potentially be treated with radio-iodine therapy to
avoid the iodine load inherent in CT contrast media. Gadolinium contrast
agents, which are usually used in MRI, can be used as an alternative for
specific patients in CT who are allergic to iodinated contrast and who have
contraindications to MRI evaluation. When necessary, the current authors
use gadolinium as an alternative contrast agent in CT.
All scans are not equal, and to answer the pertinent clinical questions,
properly performed scans are needed. The current authors begin all CT
imaging for head and neck cancer above the orbit to include the skull base
foramina and pterygopalatine foramen. The authors previously used single
detector helical scanners with 5-mm thick sections at 5 mm intervals with 3
mm sections through the larynx. Currently, with multidetector scanners, it is
possible to scan with 2.5 mm section thickness and 2.5 mm section interval
through the entire neck without significant time constraints. Multiplanar
and three-dimensional models can be readily obtained from these data,
including CT angiography as needed to assess vessel–tumor relationships.
Artifacts on CT at the oral cavity can limit the evaluation of the intrinsic
tongue and hard palate; sections angled through the oral pharynx using
a coronal oblique orientation can result in improved visualization of these
areas with a minimum of effort (Fig. 1). It is important to find an imaging
center that uses techniques such as these, with an effort to guide the
treatment plan of the individual patient in the proper direction.
16 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
Fig. 1. (A) Scout image from a CT scan of the neck and skull base for SCC shows dental
hardware and the usual scan section orientation. (B) The axial section from the angle scanned in
A at the level of the oral pharynx has extensive artifact from dental hardware, which obscures
the pharyngeal and parapharyngeal structures (arrow). (C) Scout image with coronal oblique
sections planned to avoid dental artifact through the oral pharynx. (D) The oral pharyngeal
walls and tonsils are now visible with associated left-sided mass (arrow).
nerves is best seen with imaging [10,11]. The findings may affect the choice of
radiation field needed to cover a lesion and can affect the surgical options
offered to the patient. The extent of tumors can frequently be observed
through the submucosal spaces on the images, resulting in higher tumor
staging than is suspected on clinical grounds, whereas in other cases the
clinical staging is confirmed. The images are key in defining the final extent
of the tumor (Figs. 3 and 4). Invasion of tumor into adjacent structures,
such as the mandible, or along perineural pathways may be clinically
inconspicuous. The sensitivity and specificity of imaging in detecting these
patterns of disease is well described in the literature; MRI is the preferred
method for detecting perineural disease and mandibular invasion [10–19].
Most reports to date have not accounted for recent advances in CT
technology, including multidetector scanning. The current authors have
found that perineural spread, although more obvious on a high-quality,
motion-free MRI, is detectable on CT, in most cases, by loss of the normal
fat signal at the foramen [10,18–19]. Perineural spread of tumor is usually
the result of squamous cell carcinoma (SCC), although this finding is likely
caused by the prevalence of this tumor in the population. Perineural spread
is also commonly seen in adenoid cystic carcinoma, followed by
mucoepidermoid carcinoma [10,18]. Because perineural spread is present
in a higher percentage of cases in these relatively rare tumors, MRI may
provide a more sensitive assessment of the extent of disease for salivary
Fig. 2. Axial section from a contrast-enhanced CT scan with a subtle high-attenuation lesion
(arrow) that represents a T1 SCC. This finding was much more apparent on clinical
examination.
18 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
Fig. 4. (A) Axial contrast-enhanced CT of the neck reveals a high-attenuation mass in the right
pharyngeal tonsil (arrow). (B) A section lower in patient shown in A demonstrates involvement
of the tongue as the tumor spreads anteriorly along the palatoglossus muscle (arrows). (C) A
section higher than that shown in A reveals some early spread to the soft palate as well (between
arrows).
Fig. 5. (A) Sagittal T2-weighted MRI image reveals a large intracranial component to this
esthesioneuroblastoma (arrows). Note the cystic and solid components of the mass, which is
a characteristic of these tumors. (B) The coronal T1 fat-saturated gadolinium-enhanced image
reveals the heterogeneous enhancement of this lesion and its sharp demarcation from the brain,
which is not yet invaded (arrows).
well. Perineural spread from the masticator space usually involves cranial
nerve V and specifically its third division (see Figs. 6 and 7).
Imaging of the infrahyoid neck is less complex overall but requires
knowledge of laryngeal anatomy and operative approaches. Most infra-
hyoid head and neck tumors are SCC or metastatic disease to the lymph
nodes. Three-dimensional and multiplanar modeling of the CT data can
provide the surgeon with a better appreciation of the anatomy pre-
operatively, providing a more surgically oriented perspective of the
pathology and, in some cases, allowing for production of synthetic
prostheses to be prepared preoperatively to fit the patient’s anticipated
surgical defect [20–22]. The normal distribution of adipose tissue in the
larynx allows clinicians to differentiate the false from the true vocal cords on
CT and to see the paraglottic space (see Fig. 10; Fig. 11). The various
surgical approaches to laryngeal cancer include supraglottic and supra-
cricoid laryngectomy and vertical hemilaryngectomy and total laryngecto-
my. Diagrams of these procedures can be modeled from modern CT images
(see Fig. 11; Figs. 12 and 13). For patients with laryngeal tumors, the images
can define extension of a primary neoplasm in the paraglottic space across
the laryngeal ventricle or across the midline that would render supraglottic
or vertical hemilaryngectomy unlikely to provide tumor-free margins. This
finding would affect the potential for operative cure in these patients. With
this information, the head and neck surgeon can have a more informed
discussion with the patient regarding potential operative options and
prognosis. CT provides the best, most rapid, and consistently motion-free
images in this population. MRI is more sensitive for invasion of the thyroid
R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35 21
Fig. 6. (A) Axial contrast-enhanced fat-saturated T1 image of the suprahyoid neck reveals
a nodule of enhancing tissue (arrow) in the mandibular foramen of this patient who has
a retromolar trigone SCC. (B) Contrast-enhanced axial CT section in the same patient shows
the lack of fat signal typical of perineural spread in the same mandibular foramen imaged 3
weeks earlier (curved arrow). Note the normal fat signal in the foramen of the contralateral side
(straight arrow). (C, D) The invasion of the mandibular marrow space is clearly seen in these
coronal and axial contrast-enhanced T1-weighted MR images from the same patient (arrows).
Fig. 7. (A) An axial contrast-enhanced T1-weighted image from an MRI of the neck reveals an
enhancing mass at the top of the right masticator space just below foramen ovale (between
arrows). (B) A coronal contrast-enhanced T1-weighted image reveals the perineural spread of
the tumor into foramen ovale along cranial nerve V3 to involve Meckel’s cave (long arrow).
Compare this to the normal contralateral side (short arrow).
Nodal staging
Staging of nodal disease in the neck traditionally has been based on
clinical examination; however, limitations in the clinical examination result
in relatively low sensitivity and specificity (60%–70%), leading to an
unacceptably low negative predictive value [3,4,23]. Improved negative
predictive value is important in defining a population that would benefit
from surgery without the need for neck dissection and radiation. Imaging,
including CT and MRI, uses a threshold size to determine if a node is
abnormal. Depending on the reference, this size varies between 1 and 1.5
cm. Morphology of the node is also considered in determining the likelihood
of metastasis, including the transverse-to-longitudinal ratio and the
R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35 23
Fig. 8. An axial section from a contrast-enhanced CT of the neck reveals loss of the normal fat
attenuation within the left pterygopalatine fossa (arrow). This finding was confirmed to be
perineural spread from the patient’s left tonsillar fossa SCC.
Fig. 10. (A) Axial CT section of the larynx a t the level of the false cords (arrows). Note the low
attenuation of the paraglottic fat. (B) Axial CT section at the level of the paraglottic space
shows the fat within the space to better advantage (arrows). (C) Coronal reformation from the
same scan shows the fatty attenuation in the paraglottic space (long arrow) and false cords (short
arrow) compared with the muscle attenuation of the true vocal cords (curved arrow). (D) Off-
midline sagittal reformat from the same patient clearly shows the air within the laryngeal
ventricle (long arrow). The false cords are above the ventricle with the muscular true cords
below.
Fig. 11. (A) An axial contrast-enhanced CT scan at the level of the true vocal cords (arrow).
Note the high attenuation (muscle) of the true vocal cords compared with the false cords seen in
Fig. 10. The line delineates the surgical resection for a vertical hemilaryngectomy. Because the
cricoid cartilage is preserved by the surgery, extension of tumor into the cricoid or arytenoid
would contraindicate this type of voice-sparing procedure. (B) A color three-dimensional
diagram of the larynx, again showing the surgical plan for a supracricoid laryngectomy. The
thyroid cartilage is blue, the cricoid cartilage is light blue, the epiglottis is red, and the hyoid
bone is white.
nodes have had some success, but the sensitivity is only marginally improved
over that of MRI or CT [25,26]. Combined MRI and CT have approached
90% sensitivity for metastatic node detection in one study [1]. It would seem
that, regardless of imaging technique, negative predictive value has not
achieved a level that would be clinically useful in excluding clinically N0
neck disease without unacceptably low positive predictive values.
Until negative and positive predictive values of nodal disease are
improved, exclusion of patients from treatment of the neck with radiation
or neck dissection based on imaging is not appropriate; however, there are
other uses for nodal assessment with imaging that can affect patient care and
prognosis. The location of nonpalpable adenopathy in the neck in patients
who have disease of any nodal stage can affect the size and extent of
radiation fields and the side and extent of neck dissection. Given the
increased sensitivity of image-based nodal staging compared with clinical
staging, this is sufficient to warrant nodal evaluation with imaging.
The description of nodal locations in the neck requires precise language
to facilitate communication between the head and neck radiologist, the
surgeon, and the pathologist. Without such a system, patterns of nodal
disease and their relationships to tumor prognosis and location would lack
precision and result in inaccuracies in clinicians’ knowledge of disease
prognosis and patterns of spread, limiting their ability to treat patients.
Various classification systems for nodal disease in the neck therefore have
been used in the past, including those of the American Academy of
26 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
Fig. 12. (A) Sagittal CT reformatted image of the neck reveals the resection plan for
a supraglottic laryngectomy. Note the line goes through the laryngeal ventricle and spares the
vocal cords. (B) Coronal section reformatted from the same scan shows the surgical plan
through the laryngeal ventricle between the true and false vocal cords. (C) Color volume–
rendered model of the larynx again reveals the surgical margin. The thyroid cartilage is blue, the
cricoid cartilage light blue, the hyoid bone is white, and the epiglottis is red.
Fig. 13. (A) An axial CT reformatted image at the level of the true vocal cords demonstrates the
surgical plan for a supracricoid laryngectomy. Note the cricoid cartilage is spared and only one
arytenoid cartilage is resected. (B) A sagittal section of the same scan shows the two possible
plans for the supracricoid laryngectomy, with and without preservation of the epiglottis.
and below the mylohyoid muscle. Level IA is between the anterior bellies of
the digastric muscles, with level IB lateral to the digastric muscle anterior
belly. Level II extends from the skull base to the bottom of the hyoid bone,
posterior to the back of the submandibular gland, and anterior to the back
of the SCM muscle (Fig. 14). Level IIA consists of nodes in the level II
region that are inseparable from the jugular vein by a fat plane, with level
IIB nodes posterior to the vein and separable from it by a fat plane. Level III
nodes are anterior to the back of the SCM muscle and between the bottom
of the hyoid bone and the bottom of the cricoid arch (Fig. 15). Level IV
nodes are located below the bottom of the cricoid arch but above the
clavicles. They are anterior to the line joining the back of the SCM muscle
with the posterolateral margin of the anterior scalene muscle, and lateral to
the common carotid arteries. Level V nodes are posterior to the back of the
SCM muscle from the skull base to the bottom of the cricoid arch (level VA)
and continue posteriorly to the line connecting the back of the SCM muscle
and the posterolateral margin of the anterior scalene muscle to the level of
the clavicle (level VB). Level VI nodes are between the common carotid
arteries from the bottom of the hyoid bone to the top edge of the
manubrium, with level VII nodes located between the carotid arteries below
the top edge of the manubrium to the level of the brachiocephalic vein. The
level of the clavicles is defined as the first axial section in which the clavicles
are visible. The supraclavicular nodes are at the level of the clavicles lateral
to the common carotid arteries. Retropharyngeal nodes are defined as
medial to the internal carotid arteries, within 2 cm of the skull base.
This system provides the precise framework needed to facilitate
communication among and between surgeons, pathologists, and radiolog-
ists. Although all nodal levels may not be commonly used by surgeons in all
28 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
Fig. 14. An axial contrast-enhanced CT section reveals metastatic adenopathy at level IIA on
the right and the left (arrows). Nodes are above the bottom of the hyoid bone, posterior to the
back of the submandibular gland, and anterior to the back of the SCM muscle, inseparable
from the jugular vein. Note that the nodes are enlarged, abnormal in shape (rounded), and
abnormally low in attenuation.
for multiple passes with a 22-guage needle into the substance of the mass,
without additional percutaneous passes and with good maintenance of an
entry point close to the tumor margin (Fig. 16). From this approach, the
guide needle can be angled slightly at the skin surface to obtain samples at
different locations within the tumor mass, with minimal additional risk. The
current authors have performed biopsies in 38 patients using this technique
over the last 4 years without complication. Sufficient tissue for diagnosis was
obtained in 98% of patients who underwent biopsy.
The use of imaging in postoperative patients is perhaps the most difficult
part of head and neck imaging interpretation for the radiologist. MRI in the
postoperative setting frequently proves difficult for patients, because motion
and suspension of swallowing can be difficult to control. MRI has been
shown to have a high false-positive rate after radiation, which increases over
time to as high as 58%; CT has a specificity and sensitivity of 80% to 90%
[30,31]. Knowledge of the surgical procedure performed and the type or
location of any operative flap reconstruction, and history of radiation
treatment, will decrease the false-positive rate in MRI. This again
emphasizes the need for communication between surgeons and radiologists
to obtain accurate evaluation of the patient and the optimal imaging
technique [32]. Recognition of the post-treatment appearance of head and
neck cancer on CT is an acquired skill that requires practice and readily
available follow-up information for the radiologist to become proficient.
30 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
Fig. 16. (A) An axial CT section of the neck without contrast reveals a lateral pharyngeal node
on the left (arrow). The section includes part of the biopsy guide needle in the buccal space.
(B) This section shows the biopsy needle piercing the lateral pharyngeal node. Note the initial
scan was obtained with contrast to locate the carotid artery, which was clearly lateral to the
node before biopsy.
The operative flaps typically contain fat and muscle, with identifiable
vascular pedicles. The postradiation density of tumor is intermediate
between muscle and fat but may maintain the shape of the original neoplasm
(Fig. 17). The initial evaluation of PET scanning in recurrent disease and for
tumor response to chemotherapy has been promising [33–35], with some
articles stating improved sensitivity of PET over MRI and CT for
evaluation of recurrent disease. Overall patient numbers have been low in
these studies, however. Other studies have implied PET has a role during
initiation of chemotherapy to evaluate initial tumor response using glucose
metabolism as an indicator of tumor response. A lack of metabolic change
with initiation of therapy implies therapy may not be effective [31]. This
finding could potentially provide an early indicator that a new therapeutic
regimen should be considered.
The role of any radiologist is to provide the clinician with important
anatomic details about the patient that may affect the difficulty or feasibility
of the planned therapeutic approach. This communication is particularly
important with head and neck malignancies. The use of three-dimensional
and multiplanar reformatted images in CT or MRI to help define tumor
relationships to vessels and the likelihood of vascular, spinal, perineural, or
tracheal invasion is crucial. Controversy still exists as to whether CT or
MRI performs these perspective tasks with higher sensitivity, but the well-
trained eye, and the clinician who is informed of the planned clinical
procedure and is aware of the surgical approach and risks, is the best tool
for alerting the surgeon to potential pitfalls related to anatomic variants in
a specific patient (Figs. 18 and 19).
R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35 31
Fig. 17. (A) An axial contrast-enhanced CT section through the larynx at the level of the
paraglottic space reveals a high-attenuation mass crossing the laryngeal ventricle through that
space (arrow). (B) The coronal reformatted image from A confirms the paraglottic spread of the
tumor (arrow). This tumor also extended across the midline anteriorly, excluding the patient
from voice-preservation surgery. (C) A follow-up CT scan after radiation therapy in the same
patient reveals the typical low attenuation of treated tumor, which is between muscle and fat
density (arrow). (D) A coronal reformation of C confirms that the paraglottic space also shows
evidence of radiation effect (arrow). Note that the mass effect from the tumor has not yet
subsided and continues to indent the supraglottic airway.
Summary
Evaluation of head and neck cancer with imaging is a topic that is far
more extensive than can be covered in this article. The main reason for head
and neck imaging is to evaluate the true extent of disease to best determine
surgical and therapeutic options. This process includes evaluation of the
size, location, and extent of tumor infiltration into surrounding vascular and
visceral structures. Important anatomic variants must be pointed out so the
surgeon can avoid potential intraoperative complications. These variants
can be evaluated with the appropriate multiplanar and three-dimensional
images to provide as much information as possible to the surgeon
32 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
Fig. 18. (A) An axial contrast-enhanced CT section at the level of the hard palate in a patient
with a superficial palatal carcinoma on clinical examination reveals an asymmetry in
attenuation and size of the greater palatine foramen (solid arrow). Compare this to the normal
side (open arrow) in which the attenuation is normal and the foramen is comparatively small.
(B) A bone window of the same section demonstrates the size asymmetry to better advantage
(arrows). (C) Sagittal reformatted image of the mass demonstrates the lack of fatty attenuation
at the opening of the palatine foramen on the left (arrow). (D) Sagittal reformatted image of the
normal side reveals the expected normal fatty attenuation. This finding is consistent with
perineural spread on the CT and changed the surgical plan from intraoral resection to a split
mandible procedure with partial resection of the maxilla. Perineural tumor in the greater
palatine foramen was found pathologically.
Fig. 19. (A) A volume-rendered CT laryngoscopy view reveals a posterior bulge in the wall of
the upper hypopharynx (arrows). (B) The cutaway view of the same image reveals a densely
enhancing structure in the submucosa of the retropharyngeal space (arrow). (C) An axial
contrast-enhanced CT section reveals the mass to be secondary to a tortuous carotid artery,
which resulted in a retropharyngeal position of the carotid bifurcation on the right (arrows).
This finding was brought to the attention of the head and neck surgeon.
investigation along a different path, saving the patient unnecessary risk and
shortening the time to diagnosis and ultimate treatment.
This article has attempted to detail the current state of the controversy
between CT, MRI, and other modalities, and has emphasized the constant
evolution of this controversy because of the evolving imaging technology.
Although CT and MRI are both well suited to evaluation of the deep spaces
and submucosal spaces of the head and neck, each has some limitations.
MRI has the advantages of higher soft tissue contrast resolution, the lack of
iodine-based contrast agents, and high sensitivity for perineural and
intracranial disease. The disadvantages of MRI include lower patient
tolerance, contraindications in pacemakers and certain other implanted
metallic devices, and artifacts related to multiple causes, not the least of
which is motion. CT is fast, well tolerated, and readily available but has
34 R.A. Alberico et al / Surg Oncol Clin N Am 13 (2004) 13–35
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doi:10.1016/S1055-3207(03)00121-2
38 M. Sullivan / Surg Oncol Clin N Am 13 (2004) 37–46
complications associated with head and neck radiation. At this juncture, the
importance of impeccable oral hygiene can be emphasized. Recently, the use
of topical fluoride varnishes containing 5% sodium fluoride (eg, Duraphat,
Ivoclan, NA, Amherst, New York) have been shown to be effective in
preventing decay in the xerostomic population [8]. The topical fluoride varnish
is applied on the surfaces of all teeth. A daily fluoride delivery system is also
recommended. Many different means of fluoride delivery have been explored
in the literature [9,10]; these include the fabrication of custom fluoride carriers,
containing a 0.4% stannous fluoride product, which are worn nightly for 5 to
10 minutes. If this process is perceived to be arduous by the patient, the use of
a 1.1% fluoride paste is prescribed. Also at this time, an evaluation for
xerostomia is rendered based on the location of the tumor and the type of
subsequent radiation required. Historically, the radiation oncologist is
consulted regarding the use of a salivary stimulant, such as pilocarpine
(Salogen, MGI Pharma, Inc., United Kingdom), in an attempt to maintain
salivary function [11–13]. Pilocarpine (Watson Laboratories, Corona,
California) is a parasympathomimetic agent that stimulates exocrine gland
tissue. This action promotes salivation and is believed to be most effective if
administered at the onset of radiation. In a recent study, pilocarpine
administered during and after radiation therapy was found to offer no benefit
[14]. Amifostine (Ethyol, Medimmune, Inc., Gaithersburg, Maryland) has
been investigated for its use as a chemoprotectant, which reduces the severity
of radiation-induced mucositis and maintains salivary function in patients
with head and neck cancer undergoing radiation therapy [15–18]. This agent
must be administered daily throughout radiation therapy, with profound
hydration, to be effective without significant side effects. Although amifostine
shows promise, further controlled clinical studies must be performed.
Patients who are at high risk for developing trismus should be given
instruction for its prevention rather than treatment once it occurs. Patients
requiring resection of part of the mandible without reconstruction are at
considerable risk, especially if postoperative radiation is required. Those
patients who require partial maxillectomy that includes the tuberosity,
hamular notch region and the pterygoid fossa area are at risk, especially
if postoperative radiation is required. For tumors located within the
nasopharynx, in which the muscles of mastication and the temporomandib-
ular joint are within the field of radiation, trismus therapy must not be
overlooked. Daily opening exercises can be a worthwhile task for minimizing
this debilitating complication. Instructing patients on the use of tongue blades
to use as a lever and monitoring the range of opening can be useful as well [19].
The use of chemotherapeutic agents in the treatment of head and neck
cancer historically has not been as widely used as surgery or radiation.
Chemotherapy was reserved for advanced-stage disease or as an adjunct
when front-line treatment failed. For head and neck malignancies, chemo-
therapy can be used before surgery to decrease the possibility of distant
metastases, or it can be used concurrently with radiation therapy.
40 M. Sullivan / Surg Oncol Clin N Am 13 (2004) 37–46
Summary
A comprehensive dental oncologic screening should be part of the
pretreatment workup of patients who have head and neck cancer. This
screening should be performed by a dentist who is familiar with the
pathologic process of disease and type of treatment being rendered; in
addition, he or she should comprehend the various morbidities associated
with eradicating head and neck malignancy. The dental oncologist must
provide the timeline for the surgeon and radiation oncologist in which all
necessary dental treatment will be completed. It is important at this juncture
44 M. Sullivan / Surg Oncol Clin N Am 13 (2004) 37–46
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46 M. Sullivan / Surg Oncol Clin N Am 13 (2004) 37–46
* Corresponding author.
E-mail address: patrick.gullane@uhn.on.ca (P.J. Gullane).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00123-6
48 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
Etiology
Predisposing factors in the development of oral cavity SCC can be
divided into those that are specific to the patient and those of environmental
origin. Most patients are men with a median age of 60 years [5]. There is an
increasing trend of this disease in women, however, who now account for
approximately 30% of all cases [6]. A recent Canadian report showed that
the incidence of oral SCC in women increased by 84% over the period
from 1983 to 1997 [7]. In addition, the incidence of oral cavity SCC is
approximately 4% in patients younger than 35 years [6].
The dominant causative environmental factor in the development of oral
SCC is smoking. This factor combined with the chronic consumption of
alcohol constitutes a 35-fold greater risk for developing an oral cavity
malignancy [2,8]. A constant and prolonged exposure to these two known
causative factors results in ‘‘field cancerization’’ of the oral mucosa [9]. The
mechanisms are multifactorial and include activation of proto-oncogenes
and deactivation of tumor suppressor genes. Genomic instability develops,
and this results in a chain of events that ends in the development of
malignancy with the potential for local destruction and distant spread
[10,11].
The culturally specific habits of chewing betel nuts and tobacco and
reverse smoking are also implicated in the cause of oral cavity SCC [12,13].
Although lip carcinoma is included within the oral cavity, it is important to
recognize that it may be caused by excessive exposure to ultraviolet
radiation and therefore should be classified more appropriately as a skin
carcinoma [14]. Other factors, such as poor oral hygiene, significant
periodontal disease, and chronic trauma from ill-fitting dentures or jagged
teeth, also have been proposed as potential causative factors. In addition
there are several other oral pathologic conditions that are potential
precursors in the development of malignancy, which include erosive lichen
planus, oral submucous fibrosis, erythroplakia, leukoplakia, and possibly
chronic hypertrophic candidiasis [2]. An association with Epstein-Barr virus
and the human papilloma virus has been suggested, but clear causation has
not yet been established [15–17].
Pathology
SCC accounts for approximately 90% of all oral cavity malignancies [5].
In the differential diagnosis, however, minor salivary gland carcinomas,
lymphoma, melanoma, mesenchymal tumors, and tumorlike conditions
must be considered. Submucosal malignancies arising at the junction of the
hard and soft palate often originate in the minor salivary gland and may
include adenoid cystic, mucoepidermoid, or acinic cell carcinoma. Mucosal
melanoma needs to be considered in the differential diagnosis of a bluish
mass on the alveolus. Other mesenchymal tumors, such as osteosarcoma,
C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70 49
Fig. 1. Oral cavity subsites. (Modified from Sharma PK, Schuller DE, Baker SR. Malignant
neoplasms of the oral cavity. In: Cummings CW, et al, editors. Otolaryngology–head and neck
surgery. Vol. 3, 3rd edition. St. Louis, MO: Mosby; 1998; with permission.)
50 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
these lesions are therefore usually diagnosed at an early stage (ie, T1 or T2).
Neoplasms that originate in the floor of the mouth and along the lower
alveolar ridge tend to invade the mandible early, and patients may present
with loosening of teeth and ill-fitting dentures. The retromolar trigone is
a less common site for oral cavity SCC but deserves special mention. These
tumors spread early to involve adjacent sites such as the mandible, tongue
C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70 51
base, tonsil, and soft palate. Once these lesions have extended beyond their
site of origin, treatment becomes more complex, with significant ablative
and reconstructive challenges. The hard palate and maxillary alveolus are
involved in approximately 10% of cases [5]. Aggressive local invasion
frequently occurs with extension to involve the paranasal sinuses,
pterygopalatine fossa, infratemporal fossa, orbit, and/or the cranial cavity.
SCC of buccal mucosa may occur de novo or become involved by way of
direct extension from other oral cavity subsites. This site includes all the
intraoral lining of the inner surface of the cheeks and lips from the line of
contact anteriorly to the pterygomandibular raphe posteriorly and attaches
to the superior and inferior alveolus. The buccal mucosa is a common site of
origin in India and the southeastern parts of the United States because of
the high incidence of betel nut chewing in the former and the use of snuff in
the latter [12,13]. SCC of the lip commonly occurs in white individuals who
have a life-long outdoor occupation [2].
Oral cavity SCC presents with regional cervical lymph node involvement
in a significant proportion of patients. The incidence of regional metastases
is associated with subsite, stage, and various histopathologic features (eg,
depth of invasion, malignancy grading of the tumor front, pattern of
invasion, growth pattern, and lymphovascular and perineural invasion) [19–
22]. For example, neoplasms that are larger than 2 cm, have depth of
invasion greater then 3 mm, and tend to invade in small groups of tumor
cells have been associated with a significant rate of occult nodal metastases
[23]. Potential molecular markers (ie, tumor suppressor genes and proto-
oncogenes) have been proposed as indicators for regional involvement, but
their routine application has yet to be proved [11,24].
Management
The management of patients who have oral cavity SCC begins with
a comprehensive history and complete head and neck examination, which
includes an office-based fiberoptic-endoscopic evaluation of the upper
aerodigestive tract. In addition, it is vital to confirm any comorbidities,
degree of functionality, family support, and understanding and personal
wishes of the patient before embarking on any therapeutic path. Treatment
modalities are divided into surgical and nonsurgical options or a combination
of both. Surgery is further subdivided into ablative and reconstructive
approaches. Nonsurgical management includes the use of radiotherapy,
chemotherapy, and ancillary services aimed at functional rehabilitation (Fig.
2). The selection of appropriate therapy depends on certain patient, tumor,
and institutional factors. Patient factors have been outlined previously, and
those pertaining to individual tumor sites are discussed later. Institutional
factors relate to the expertise, resources, and treatment philosophy established
by the multidisciplinary team. Various therapeutic philosophies exist, and
these need to be considered in the management of each individual patient.
52 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
Investigations
Investigations can be divided into those that are general and specific and
include a complete blood film, biochemistry, ECG, and a chest radiograph.
Specific investigations should include imaging of the primary tumor site and
C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70 53
Specific sites
Tongue
Surgery is the mainstay of treatment for early-stage disease of the oral
tongue (ie, stages I or II) [29]. Adjuvant radiotherapy improves locoregional
control and disease-specific survival rates in patients with advanced-stage
lesions [30]. Chemotherapy in a neoadjuvant setting has been investigated
and shows promise; however, its use is presently limited to institutional trials
54 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
[31]. Palliative chemotherapy useful and can be offered to patients for whom
definitive curative management is no longer an option.
There are several surgical approaches to disease of the oral tongue. These
include the peroral, degloving, mandibular swing (ie, by means of midline,
paramedian, or lateral osteotomies), lingual release, or cheek flap approach
[32,33]. The approach selected depends on several factors, which include size
of the primary tumor, mandibular invasion, dentition, extent of cervical
lymph node involvement, need for reconstruction, and the expertise and
preference of the individual surgeon. Neoplasms staged T1 or T2 that do not
invade the mandible are best managed using a peroral approach (Fig. 3).
More advanced lesions, however, particularly those that have deep tongue
involvement and extent across the midline require a more radical approach.
Both the mandibulotomy and lingual release afford good access, both for
tumor ablation and subsequent reconstruction [32,33]. The advantage of the
tongue drop is the avoidance of an osteotomy with its associated
complications of malunion and/or nonunion [34]. Prior radiotherapy can
increase the rate of complications that occur with a mandibular swing. In
expert hands, however, complication rates are low, and a recent comparison
of these two approaches showed no significant difference in outcome [35].
Patients treated with a mandibulotomy did report superior ability of speech,
swallowing, and chewing when compared with the lingual release group,
Fig. 3. (A) Right T2 lateral tongue SCC; (B) transoral resection of lesion; and (C) primary
closure with absorbable suture.
C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70 55
Fig. 4. (A) Lip-split and midline mandibulotomy approach to the oral cavity. (B) Repair with
radial forearm flap and plate.
however. The potential negative impact of a facial scar was not borne out in
this analysis [35].
Mandibular swing with either a midline or paramedian osteotomy is the
current authors’ preferred approach to the oral cavity (Fig. 4). In patients
with teeth, care needs to be taken in placing the osteotomy site between the
tooth roots; however, if there is dental crowding, extraction of one tooth is
preferred. Commercially available plating systems have improved recon-
struction and have diminished morbidity. It is important to reduce the
prominence of the symphyseal region of the mandible using a high-power
burr to compensate for the thickness of the reconstruction plate. Once this
has been achieved, a thin titanium (eg, 2.3-mm) plate is used to stabilize the
56 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
The lip
Most lip cancers occur on the sun-exposed lower lip; approximately 7%
arise from the upper lip and 4% involve the commissure. Simple excision
and primary closure is advocated in defects that involve less than one third
of the lip. Some form of advancement flap is necessary if the defect exceeds
30% of the lip, and the Abbe and Karapandzic flaps are the reconstructive
options of choice (Fig. 6) [40]. Total lip replacement, however, usually
requires free-tissue transfer, and a combination of the radial forearm free
Fig. 6. (A) Lower lip SCC; (B) excision and outline of bilateral Karapandzic advancement
flaps; (C) flap advancement and closure; and (D) Postoperative result.
58 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
flap and the palmaris longus sling has become a popular option [41].
Primary radiotherapy is an alternative form of treatment, especially in
elderly patients and in those who are medically unfit for prolonged
anesthesia and hospitalization. Treatment of the cervical lymphatics (ie,
neck levels I to III) should be considered in patients with neoplasms that
involve either the upper lip, the oral commissure, or in those with advanced
(ie, tumor stage, [T2) or recurrent lesions, because these lesions have
a significant incidence of occult metastases [42].
The mandible
Mandibular involvement has significant implications for both prognosis
and postoperative rehabilitation. In addition, adjuvant radiotherapy is
recommended in most patients with mandibular invasion. Currently, there is
no one diagnostic modality that provides accurate preoperative assessment
of bone invasion. Careful clinical examination is paramount, however, and
studies have shown it to be highly sensitive ([94%) but lacking in specificity
(25%) [27]. In certain situations, including those in which lesions are close to
and abutting the inferior alveolar ridge, immobile lesions of the floor of the
mouth and/or in edentulous patients are highly suggestive of bone invasion.
A combination of Panorex/occlusal views and CT scanning has a high
sensitivity (81%) and specificity (88%) [27]. SPECT and MRI also show
promise, with reported sensitivities of more than 90%, but their limited
availability curtails their routine use [28]. The current authors’ approach to
the evaluation of the mandible includes a thorough clinical examination,
with Panorex/occlusal views, CT scans, and a high index of suspicion.
The goal of resection is to provide a clear margin of more than 1 cm with
removal of all microscopic disease. Where the mandible is involved clinically
and radiologically, the standard of care is usually segmental mandibulec-
tomy (Fig. 7). The reconstructive menu in the current authors’ institution
includes a vascularized osseous free-tissue transfer, but in select cases, where
the bony defect is situated posterolaterally in elderly and edentulous
patients, it may be left unreconstructed. The dilemma arises in lesions that
are close to or abut the mandible. A marginal mandibulectomy is a widely
accepted approach where there is no clear evidence of bone invasion [43].
This procedure involves a resection of either the superior half of the
mandible or the lingual cortex (Fig. 8). Where the resection includes more
than 60% of the height of the mandible, a plate is applied to reduce the
incidence of fracture.
The management of the mandible requires a balanced approach, with
avoidance of unnecessary, excessive resection of normal, uninvolved tissue.
Results support using a marginal mandibulectomy in most patients in whom
no gross clinical and radiologic evidence of mandibular invasion exists.
Ultimate locoregional control and survival rates compare well with those for
segmental mandibulectomy [44,45].
C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70 59
Fig. 7. (A) T4 right lower alveolar SCC. (B) Composite resection, including lateral segmental
mandibulectomy and radical neck dissection. (C) Repair with free vascularized fibular bone and
overlying skin.
The neck
The management of the neck in patients who have SCC of the oral cavity
is determined by the treatment approach to the primary neoplasm, with
most clinically involved cervical lymph nodes requiring a neck dissection.
The standard is a modified radical neck dissection encompassing levels I to
V. Recent studies, however, have questioned this approach for small, single
lymph node disease involving the upper neck. Andersen et al [46] in a recent
review reported on 106 patients with clinically positive neck disease. The
primary sites were varied with approximately half involving the oral cavity.
60 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
Fig. 8. (A) Cheek flap approach. (B) Exposure of the lateral oral cavity. (C) Posterior marginal
mandibulectomy.
was identified in 95% of patients, and the overall sensitivity of this approach
was 100%. Ross et al [55] recently presented the results of a multicenter trial
on the feasibility of this technique in the management of patients with head
and neck SCC and concluded that sentinel node biopsy identified 95% of
sentinel nodes with an overall sensitivity of 90%. The sensitivity dropped
significantly in centers performing fewer than 10 sentinel node biopsies per
year, however. Although results of this approach are promising, further
multi-institutional trials need to be performed to evaluate and test this
modality before it can become part of the routine workup in patients who
have clinically N0 neck disease. The management of clinical negative neck
disease therefore continues to be controversial, and the selection of
treatment modality generally depends on the approach to the primary
tumor. Treatment of early-stage disease is adequate with single-modality
therapy. The importance of including the neck in the treatment regime rests
on the fact that oral cavity SCC has a significant rate of occult metastases.
Even T2 lesions have a known incidence of occult disease of more than 15%,
necessitating treatment of the N0 neck. Neck dissections encompassing
levels I to III are generally adequate; however, Byers et al [56] reported that
‘‘skip metastases’’ involving only levels III or IV exist in up to 15% of
patients with oral tongue SCC. In addition, midline lesions (eg, anterior
floor of mouth) usually require bilateral neck treatment. The current
authors’ approach in the management of clinically N0 neck disease is to
perform either unilateral or bilateral selective neck dissections encompassing
levels I to IV. In addition, adjuvant radiotherapy is recommended if occult
disease is identified.
Reconstruction
A wide variety of reconstructive options are currently available to repair
surgical defects of the oral cavity [57]. The simplest approach is to permit the
defect to heal by secondary intention, and this is certainly appropriate for
small lesions of the tongue, floor of the mouth, or buccal mucosa. Split-
thickness skin grafting is an alternative; however, in large defects, there
exists a significant rate of fistula formation, trismus, and graft failure [58].
Local mucosal, tongue, or skin flaps (eg, nasolabial) are alternate options,
and these are best suited for defects that involve the anterior floor of the
mouth, especially in edentulous patients [59]. The gold standard in soft
tissue reconstruction of the oral cavity is the radial forearm free flap [60]. It
provides significant flexibility to the surgeon because of the size of the
potential skin paddle and adequate length of its vascular pedicle. It is thin,
pliable, and potentially sensate and therefore well suited for intraoral
reconstruction, with minimal failure rates (Fig. 9) [61].
Three options are available for managing segmental mandibular defects.
The first option is to leave posterolateral defects unreconstructed (eg, in
62 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
Fig. 9. (A) Cosmetic result of the lip-split approach. (B) Postoperative appearance of the radial
forearm free flap for the repair of lateral oral tongue defects.
elderly and edentulous patients) and manage these defects with only soft
tissue replacement (eg, pedicled mycocutaneous or free soft tissue flap).
Simple plate reconstruction is another alternative; however, this modality is
associated with high extrusion rates despite adequate soft tissue cover (eg,
pedicled mycocutaneous or free soft tissue flap) and therefore is usually not
recommended as a primary reconstructive approach (Fig. 10) [62–64]. The
gold standard approach today is the use of an osseocutaneous free-tissue
transfer (eg, fibula, iliac crest, or scapular free flap) [65].
Rehabilitation
Post-treatment rehabilitation is vital in patients with oral cavity SCC
because significant functional morbidity is encountered that affects speech,
swallowing, and/or mastication. Oral rehabilitation commences at the time
of initial consultation and is coordinated by a speech pathologist. Input
from a dentist and prosthodontist, however, is also vital for successful and
expedient rehabilitation in these patients.
C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70 65
may become useful in the management of patients who have oral cavity
SCC.
Summary
Oral cavity SCC remains a significant health problem and requires
a multidisciplinary approach. Treatment with surgery alone or in
combination with adjuvant radiotherapy for more advanced lesions is the
standard of care. Major advances have been made in surgical approaches,
reconstructive options, and the rehabilitation of patients who have oral
cavity SCC. These advances have significantly improved disease-specific
outcome and quality of life. The future may lie in the development of
treatment regimes that combine early detection with organ preservation and
result in improved cure rates and quality of life.
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70 C.E. Palme et al / Surg Oncol Clin N Am 13 (2004) 47–70
Relevant anatomy
The superior and inferior boundaries of the oropharynx are marked by
horizontal planes at the levels of the hard palate and vallecula or hyoid
bone, respectively. The muscular pharyngeal wall between these two planes
defines the posterior limits. The circumvallate papillae and palatoglossal
muscle mark the anterior limits. Most of the lateral wall of the oropharynx
is primarily composed of the tonsil and the tonsillar fossa. A small
contribution comes from the lateral extensions of the posterior pharyngeal
wall. The oropharynx can be divided into four subsites: (1) the posterior
pharyngeal wall, (2) the soft palate, (3) the tonsil complex (ie, tonsil,
tonsillar fossa, and pillars), and (4) the base of tongue. The limits of the
oropharynx as a whole can usually be easily appreciated during clinical
* Corresponding author.
E-mail address: jimbrown@cdrewu.edu (J.J. Brown).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00117-0
72 R.F. Osborne, J.J. Brown / Surg Oncol Clin N Am 13 (2004) 71–80
Histopathology
In general, the histopathologic entities seen in the oropharynx represent
a derivation of tissue normally present there. Because the oropharynx is
lined with stratified squamous epithelium, 85% to 90% of carcinomas seen
are squamous cell in origin. The presence of minor salivary glands,
neurovascular and fibromuscular structures, and lymphoid aggregates in the
Waldeyer’s ring opens the possibility to a wide variety of mesemchymally
derived sarcomas and carcinomas. A discussion of the management of all
malignancies found in the oropharynx is beyond the scope of this article.
Therefore, the remainder of the article pertains to the management of
squamous cell carcinomas (SCCs) at the various subsites of the oropharynx.
Soft palate
The soft palate functions to prevent air escape during phonation and
nasal regurgitation during deglutition. Of all the subsites of the oropharynx,
it may provide the least challenge to routine examination. Thus, despite the
relatively asymptomatic presentation of carcinomas in this region, they are
usually identified early and referred for definitive management.
SCC of the soft palate is a relatively uncommon malignancy and remains
virtually asymptomatic because of its location, until a lesion reaches
a substantial size. At first glance, these lesions give the impression that they
can be readily encompassed by a surgical procedure without compromise of
function. Because of the relative infrequency of these lesions, however,
many clinicians have limited experience in their management.
The soft palate forms a mucosa-covered muscular bridge from one side of
the oropharynx to the other. There exists no true barrier to lateral tumor
spread, and the aponeurosis of the underlying musculature provides
a transient barrier at best. The lymphatic drainage is weighted in an
ipsilateral direction, yet there are well-recognized lymphatic drainage
patterns that permit contralateral spread. Therefore, even the smallest
lesions have the capability of seeding both sides of the neck with metastatic
disease. This possibility becomes more of a reality as lesions approach or
cross the midline. The effect of location on prognosis is well documented.
The overall 5-year survival rate for patients presenting with unilateral
lesions is 70.8% and drops to 51% for patients with midline or bilateral
lesions [2]. Approximately 25% of patients treated for a soft palate tumor
will present with a second primary tumor, with the floor of the mouth being
the most common secondary site [3–8].
Although early-stage soft palate lesions readily lend themselves to
primary surgical treatment, the submucosal nature of the disease demands
that adequate margins be taken to minimize recurrences. Thus, the
treatment of a small lesion often results in a large defect, which results in
functional difficulties. Modern palatal obturators and surgical reconstruc-
tive efforts have reduced the degree of functional deficits; however, these
74 R.F. Osborne, J.J. Brown / Surg Oncol Clin N Am 13 (2004) 71–80
deficits are not reduced to an appreciable level such that the resultant
functional status matches that of patients treated with primary irradiation
[4]. Because the local control rates for T1 and T2 lesions remains the same at
91% to 100% and 70% to 75%, respectively (American Joint Committee on
Cancer. Manual for Staging Cancer, 5th edition. Philadelphia: Lippincott-
Raven, 1997. pp. 29, 37.), for either surgery or radiotherapy [2,3], primary
radiotherapy is considered the treatment of choice for early-stage soft palate
lesions [3–6]. Importantly, to achieve similar control rates as radiotherapy,
the surgeon must not be conservative with surgical margins out of fear of the
functional and reconstructive challenges that may present postoperatively.
Advanced soft palate lesions portend a poor prognosis. The 5-year
disease-free survival rates for T3 and T4 lesions are 39% to 56% and 32% to
39%, respectively, for any treatment modality. Studies that have attempted
to analyze the modality which offers the best control rates are limited by
small numbers and many patient selection biases [9]. Despite these
limitations, there is strong support that surgery combined with radiotherapy
probably offers the best chance for obtaining locoregional control.
Tonsillar complex
Tonsillar carcinoma represents approximately 75% of all carcinomas
presenting in the oropharynx. Among carcinomas of the aerodigestive tract,
it ranks second only to laryngeal cancer. Unlike the soft palate, the more
cryptic locations of the tonsillar complex places this region at high risk for
being poorly visualized or overlooked by the casual examiner. This is one
reason the source of many unknown primary tumors is ultimately found to
originate in the tonsil. Furthermore, its relatively ‘‘out of the way’’ lateral
location permits normal speech and swallowing functions to carry on in the
presence of early-stage lesions (T1 and T2). Thus, the asymptomatic nature of
this disease causes many patients to present with more advanced lesions (T3
and T4) after the presence of pain, dysphagia, or dysarthria may prompt them
to seek help. Trismus or the restriction of tongue mobility usually indicates
advanced disease (T4). This symptom is likely caused by disease extension
into the musculature of the pterygoids or base of tongue, respectively.
In general, lesions involving the anterior tonsillar pillars tend to be less
invasive and rarely bulky. These lesions spread rapidly across broad
muscosal surfaces and frequently involve adjacent subsites of the
oropharynx, such as the soft palate or tongue base. In comparison, tumors
involving the posterior pillar or tonsil proper tend to be far more exophytic
and invasive but are less likely to spread to adjacent subsites until an
advanced stage of disease.
As with palatal primary tumors, early-stage tonsillar carcinomas (T1 and
T2) that remain confined to that subsite can be treated with either
radiotherapy or surgical modalities, with comparable locoregional control
and overall 5-year survival results [10,11].
R.F. Osborne, J.J. Brown / Surg Oncol Clin N Am 13 (2004) 71–80 75
versus a 47% recurrence rate when there was tongue base invasion. These
findings have been mirrored in other studies in the literature [16–18].
Therefore, the mainstay of treatment for T4 and T3 lesions that
demonstrate ulceroinfiltrative features and involve adjacent subsites of the
oropharynx has been combination therapy. The classic composite resection
with postoperative radiation offers improved locoregional control and
survival over any single-modality treatment.
A review of the literature showed that combination therapy can decrease
the rate of local recurrence by 25% to 50% when compared with
radiotherapy or surgery alone [10,14,18–20]. Perez et al [20] found a 52%
recurrence rate when patients with advanced tonsillar lesions were treated
with single-modality radiotherapy. This rate of recurrence was 33% when
combination therapy was instituted, which further supports the concept of
combined-modality therapy for advanced tonsillar carcinomas.
Tongue base
Treatment selection for base of tongue carcinomas is institutionally
driven. Some centers primarily use surgery with or without radiotherapy
[21–28]; others use primary radiotherapy and reserve surgery for salvage
[29–31]. The role of brachytherapy remains controversial. Brachytherapy
combined with external beam radiotherapy (EBRT) was initially believed to
be a superior treatment option to EBRT alone for base of tongue lesions. It
has since fallen out of favor because of the lack of data that supported its
independent use [15–18]. In addition to unacceptable local control rates,
EBRT is time-consuming, costly, requires additional personnel, and
increases the risk of soft tissue necrosis. Interstitial implants, however,
may have a role in patients with residual tongue disease who have completed
a course of EBRT and are not candidates for surgical salvage.
Centers using primary radiotherapy, such as the University of Florida,
are achieving local control rates for T1 and T2 tumors of 75% to 100%
[21,22,32,33]. Similarly, centers that approach T1 and T2 tongue base
tumors with surgery as a first-line therapy report essentially the same control
rates. Therefore, the approach to these early-stage lesions are primarily
based on the wishes of the patient, health status, institutional resources, and
the morbidities associated with each treatment the patient is willing to
accept. Strong arguments have been made from both sides about which
approach is less functionally disabling. In general, most centers favor the use
of radiotherapy to both the base of tongue and neck, followed by planned
interval neck dissection for N1 or greater neck disease. The current authors
prefer this approach as well.
Greater controversy exists in the management of advanced (T3 and T4)
tongue base tumors. Analysis of the literature to objectively compare the
efficacy of surgery with or without postoperative radiotherapy versus
primary radiotherapy is extremely difficult. There seem to be no studies
R.F. Osborne, J.J. Brown / Surg Oncol Clin N Am 13 (2004) 71–80 77
Chemotherapy
In the past, the role of chemotherapy in the treatment of oropharyngeal
carcinoma was generally considered experimental and used for palliation.
Most patients being treated with chemotherapy were either enrolled in
a study or were receiving treatment at a research-based institution.
There are now many promising cytotoxic agents currently under
investigation. There exists no way to ascertain from the literature the true
independent effects of chemotherapy on oropharyngeal carcinomas,
however, because there are no studies in which chemotherapy was used as
the sole treatment modality with curative intent. Most studies of merit used
chemotherapy for induction or concomitant therapy. Very little is known
about its role as an adjuvant therapy.
Cisplastin and 5-fluorouracil continue to be the most commonly used
agents in the treatment of oropharyngeal carcinomas. They have been
shown to improve locoregional control and survival statistics when given
with concomitant radiotherapy [36,37]. In the treatment of very advanced
oropharyngeal lesions, the role of chemotherapy has changed from
experimental to standard of care. The medical oncologist has a justified
role in the team approach to the treatment of advanced oropharyngeal
carcinomas.
Summary
The data indicate that SCC of the various subsites of the oropharynx can
be treated successfully with acceptable locoregional control and survival
rates by using either surgery or primary radiotherapy for T1 or T2 primary
lesions. Treatment success data for late-stage disease (T3 and T4) are less
R.F. Osborne, J.J. Brown / Surg Oncol Clin N Am 13 (2004) 71–80 79
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Surg Oncol Clin N Am 13 (2004) 81–98
* Corresponding author.
E-mail address: cgourin@mcg.edu (C.G. Gourin).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00122-4
82 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
Clinical behavior
The hypopharynx is described as the region of the pharynx that begins at
the level of the hyoid bone and extends to the inferior border of the cricoid
cartilage. Within the hypopharynx are three anatomic subsites: the paired
pyriform sinuses, the postcricoid area, and the posterior hypopharyngeal
wall. The pyriform sinus is the most commonly involved site, representing
more than 60% of all cases, and the postcricoid region is least commonly
involved, accounting for fewer than 5% of cases [2]. Isolated early-stage
lesions of the pharyngeal wall or pyriform sinus have the best prognosis and
long-term survival but comprise fewer than 20% of hypopharyngeal
carcinomas [3,7–10]. Tumor staging based on the American Joint
Committee on Cancer classification system (AJCC Cancer Staging Manual,
6th edition; Springer-Verlag: New York, 2003. pp. 33–45.) shows that
contiguous involvement of adjacent sites portends more advanced disease
(Box 1). The proximity of the hypopharynx to the larynx and cervical
esophagus mandates that the extent of disease be accurately determined
before embarking on treatment.
Hypopharyngeal carcinoma is unique in demonstrating a high propensity
for extensive submucosal spread. The true extent of disease may be initially
underestimated because of submucosal extension and the presence of skip
lesions [3]. Using whole organ, serial sectioning studies, Ho et al [11] found
that submucosal tumor extension was present in 60% of specimens. In one
third of patients, submucosal spread was not detectable on gross
examination, appearing histologically as tongues and islands of tumor
infiltration beneath an intact mucosa. The limits of submucosal extension in
this series were 10 mm superiorly to the oropharynx, 25 mm medially, 20
mm laterally, and 20 mm inferiorly toward the esophagus. The incidence
and extent of submucosal spread were higher in patients who had undergone
previous radiation therapy, with macroscopically undetectable submucosal
spread present in 82% of patients [11]. These data provide useful guidelines
for treatment planning.
The hypopharynx is served by an extensive lymphatic network.
Lymphatic drainage proceeds first to the jugular lymphatics and then to
the tracheoesophageal nodes, lateral pharyngeal and retropharyngeal nodes,
and the parapharyngeal space. Tumors that involve the posterior
hypopharyngeal wall and the medial wall of the pyriform sinus have
bilateral nodal drainage and have a high incidence of involvement of the
contralateral neck. Between 60% and 75% of patients will have clinically
involved neck nodes (node-positive [N+]) at presentation, and more than
one third of patients without clinical evidence of nodal disease will harbor
occult metastases [3–8]. In patients with N+ disease, zones II (72%–75%),
III (55%–72%), and IV (21%–45%) are most often affected; zones I (1%–
10%) and V (11%–15%) are less commonly affected [12,13]. Contralateral
occult metastases are present in 37% of patients with N+ disease [14]. In
Box 1. Staging of hypopharyngeal cancer
Tumor stage
Tis: Carcinoma in situ
T1: Tumor limited to one subsite of the hypopharynx and 2 cm or less
in greatest dimension
T2: Tumor invades more than one subsite of hypopharynx or an
adjacent site, or measures [2 cm but not more than 4 cm in
greatest diameter, without fixation of hemi-larynx
T3: Tumor [4 cm in greatest diameter or with fixation of hemi-larynx
T4a: Tumor invades thyroid/cricoid cartilage, hyoid bone, thyroid
gland, esophagus, or central compartment soft tissue. Note:
central compartment soft tissues includes prelaryngeal strap
muscles and subcutaneous fat
T4b: Tumor involves prevertebral fascia, encases carotid artery, or
involves mediastinal structures
Nodal stage
N0: No regional lymph node metastases
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but
not more than 6 cm in greatest dimension; or in multiple ipsilateral
lymph nodes or bilateral or contralateral lymph nodes, none
greater than 6 cm
N2a: Metastasis in single ipsilateral lymph node more than 3 cm but
not more than 6 cm in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, none more than
6 cm in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes, none more
than 6 cm in greatest dimension
N3: Metastasis in a lymph node more than 6 cm in greatest dimension
Distant metastasis
M0: No distant metastasis
M1: Distant metastasis present
TNM stage
Stage I: T1, N0, M0
Stage II: T2, N0, M0
Stage III: T3, N0, M0; T1 or T2 or T3, N1, M0
Stage IV: T4, N0 or N1, M0; any T, N2 or N3, M0; any T,
any N, M1
Used with the permission of the American Joint Committee on Cancer (AJCC),
Chicago, Illinois. The original and primary source for this information is the AJCC
Cancer Staging Manual, 6th edition (2002) published by Springer-Verlag New York
(For more information, visit www.cancerstaging.net). Any citation or quotation of
this material must be credited to the AJCC as its primary source. The inclusion of
this information herein does not authorize any reuse or further distribution with-
out the expressed written permission of Springer Verlag New York, Inc., on behalf
of the AJCC.
84 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
Treatment
Currently, several treatment options exist for patients who have
hypopharyngeal cancer. Surgery combined with radiation therapy is the
standard treatment for most patients who have hypopharyngeal carcinoma.
Radiation therapy alone also may be used and seems to be most useful for
small (T1 or T2) lesions. Hyperfractionated radiation therapy seems to
confer some advantages over conventional radiation therapy in improved
locoregional control. Finally, organ preservation therapy using chemo-
radiation is being increasingly studied and may result in larynx preservation
in one third of patients.
Table 1
American Joint Committee on Cancer TNM staging classification
N0 N1 N2 N3
T1 I III IV IV
T2 II III IV IV
T3 III III IV IV
T4 IV IV IV IV
86 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
Surgical treatment
Preoperative evaluation is critical in determining the appropriate surgical
approach for treatment of hypopharyngeal carcinoma. The location and
extent of disease determine the extent of resection required. Accurate
staging is necessary to answer the following questions: Will excision leave
a partial or circumferential hypopharyngeal defect, Will total laryngectomy
be required, and What is the extent of neck dissection that is required?
The predilection of hypopharyngeal carcinoma for submucosal spread
must be kept in mind when planning resection of the primary tumor. Wei
[18] suggested that, based on measurements of submucosal extension in
whole organ studies, an adequate resection margin in patients who have not
received previous radiation therapy is 15 mm superiorly, 30 mm inferiorly,
and 20 mm laterally. Patients who have undergone previous radiation
therapy require resection margins of 20 mm superiorly, 40 mm inferiorly,
and 30 mm laterally. The deep margin in either situation should be greater
than 1 mm to ensure complete removal of the tumor without leaving
residual disease in the prevertebral musculature [18].
Pyriform sinus
Lesions of the pyriform sinus, by virtue of their proximity to the larynx,
require at least a partial resection of the larynx for adequate excision. Early-
stage lesions, such as T1 lesions or T2 lesions of less than 2 cm, can be
treated by partial laryngopharyngectomy or extended supraglottic partial
laryngectomy. Transoral CO2 laser excision of pyriform sinus tumors
recently has been reported by one group to be effective, with results
comparable to transcervical approaches [32]. Regardless of the approach
used, aspiration is expected in the postoperative period, and candidates for
partial laryngopharyngectomy must have adequate pulmonary reserve and
be in otherwise good medical condition. Pulmonary function tests may
provide some objective measure of pulmonary function, but far more
physiologically useful is a determination of an active lifestyle and good
exercise tolerance. The ability to climb two flights of stairs (the ‘‘Ogura stair
test’’) is a reliable test of adequate pulmonary reserve [33].
Contraindications to partial laryngopharyngectomy are severe chronic
obstructive pulmonary disease, previous pulmonary resection, an inactive or
bed-ridden patient, or extension of the tumor to within 1.5 cm of the
pyriform apex. Arytenoidectomy is usually required for adequate excision of
the pyriform fossa. This procedure is unsafe for any tumor that is larger
than 2 cm; larger tumors require total laryngectomy with partial
pharyngectomy, which results in a significant partial pharyngeal defect.
Similarly, partial laryngopharyngectomy is unsafe for cancer that involves
the apex of the pyriform sinus. The proximity of the apex of the pyriform to
the postcricoid mucosa requires total laryngectomy and cervical esoph-
agectomy in addition to partial pharyngectomy for removal of the tumor
and results in a circumferential pharyngeal defect [3].
Partial pharyngeal defects may be closed primarily if sufficient mucosa
remains to give a tension-free closure over a #36 Maloney esophageal
88 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
dilator. If insufficient mucosa remains, closure may be achieved with the use
of the pectoralis major myocutaneous flap, or free-skin or visceral flaps. The
pectoralis major flap is the preferred method of reconstruction to patch
partial pharyngeal defects because of its ease of harvest, low morbidity, and
reliability. For posterior defects, the bulk of the pectoralis major flap may
interfere with swallowing, but this seems to be less of a problem with lateral
defects after resection of the pyriform fossa. The radial forearm, lateral
thigh, and jejunal free flaps may be used to fill the defect but carry
significantly higher donor site and surgical morbidity.
Circumferential pharyngeal defects require more involved reconstructive
efforts, with a greater potential for stricture formation and anastomotic
failure. Cervical skin flaps, regional flaps, such as the deltopectoral flap and
pectoralis major flap, and free-radial forearm, lateral thigh, and jejunal flaps
all have been used successfully. Cervical skin-flap reconstruction is a foreign
concept to most recently trained head and neck surgeons, but before the
development of the deltopectoral and pectoralis major flap, medially based
cervical skin flaps were used extensively to reconstruct pharyngoesophageal
defects. Wookey popularized this technique in the 1940s when he developed
a method of pharyngoesophageal reconstruction (the so-called ‘‘Wookey
procedure’’) by elevating a laterally based skin flap to form the new
posterior wall of the pharyngoesophageal defect. At a second staged
procedure several months later, medially based flaps from the original flap
were elevated and closed longitudinally in the midline to create a new
pharyngoesophageal segment [34]. The deltopectoral flap is used in a similar
fashion, by elevating and transposing the flap and, at a second staged
procedure, subsequently dividing the pedicle and closing the defect.
Both the Wookey procedure and the deltopectoral flap are associated with
a significant incidence of flap complications and, because these are staged
procedures, there are an average of three procedures before successful
reconstruction is accomplished. The length of hospitalization and the time to
oral alimentation is measured in week to months. Flap necrosis, fistula
formation, and stenosis have been reported to occur in 90% of patients who
have undergone surgical reconstruction with cervical skin flaps [35]. Because
laterally based cervical skin flaps tend to have marginal circulation at the tip,
partial flap loss occurs frequently. The incidence of complications has been
reported to be 56% with the deltopectoral flap, likely because of better blood
supply compared with cervical skin flaps [35]. Staged reconstruction of
pharyngoesophageal defects has been supplanted by newer methods of
reconstruction but may be useful when multiple reconstructive efforts fail.
The pectoralis major myocutaneous flap allows single-stage reconstruc-
tion of circumferential defects and is widely used for this purpose today. The
bulk of the pectoralis major flap makes tubing the flap difficult, similar to
attempting to roll up a telephone book. Postoperative complications,
including stenosis, stricture, and fistula formation, have been reported in
41% of patients [36]. In addition, the thickness of the pectoralis flap and its
C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98 89
Postcricoid lesions
Postcricoid tumors are usually advanced at the time of presentation and
require total laryngopharyngectomy and cervical esophagectomy. If disease
extends below the lower border of the cricoid, total esophagectomy is
required. The first-line reconstructive technique for the resulting pharyn-
goesophageal defect is gastric transposition, or the gastric pull-up. The
primary advantage of the gastric pull-up is that it allows for reliable single-
stage reconstruction with a single anastomosis. Stricture formation is
90 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
uncommon, because the only anastomosis is high in the neck where stricture
rarely occurs. The entire esophagus is removed and the stomach is
transposed through the superior mediastinum into the neck. The main
disadvantage of the gastric pull-up is a significant morbidity and mortality
from the procedure. The rate of major perioperative complications is 50%,
and the operative mortality is approximately 10% [34]. Organ necrosis
occurs in 3% of patients [38]. In addition, pulmonary complications can
occur from thoracic dissection. The weight of the stomach and gravitational
pull can cause anastomotic tension and suture line disruption. Gastric
transposition entails a complete vagotomy and pyloroplasty, and swallow-
ing after a gastric pull-up can be complicated by early satiety, reflux, and
dumping syndrome. The most common long-term complication is reflux,
which occurs in 20% of patients. Only 30% of patients develop good speech
with available techniques of voice restoration [42]. Gastric pull-up is not
warranted when disease is limited to the cervical esophagus.
Colon transposition is a second-line method of pharyngoesophageal
reconstruction when total esophagectomy is required. The right or left colon
may be used, based on the superior mesenteric artery or middle colic artery,
respectively. The distal anastomosis is made between the distal colon and
stomach. Colon interposition has been associated with a high incidence of
postoperative infection, and therefore the colon is usually placed in
a subcutaneous pocket anterior to the sternum to avoid mediastinal
complications if necrosis occurs. Colon interposition has fallen out of favor
because of a 45% incidence of major medical complications; a 25%
incidence of reconstructive complications, including necrosis, fistula and
stricture; and an overall perioperative mortality rate of 20% [35,43]. Gastric
transposition is considered the reconstructive technique of choice for total
esophageal defects, with colon interposition reserved for patients with
contraindications to gastric surgery or as a salvage technique.
Neck dissection
Because of the high incidence of nodal metastases, ipsilateral neck
dissection is warranted in all patients who have hypopharyngeal cancer.
Selective neck dissection of zones II through IV is recommended for all
patients with clinically N0 neck disease. The scarcity of metastases to zones I
and V supports sparing these zones in this scenario [12,44]. Ipsilateral
paratracheal node dissection (zone VI) should be included as part of
selective neck dissection for all patients who have postcricoid tumors and
tumors that involve the pyriform fossa apex [14]. Patients with clinical
evidence of neck disease (N+) require modified radical neck dissection or
radical neck dissection of zones I through VI.
Contralateral neck dissection is indicated in patients who have midline
lesions of the posterior hypopharyngeal wall and postcricoid tumors
because of the increased incidence of occult contralateral metastases.
Patients who have laterally situated tumors are usually treated with
C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98 91
ipsilateral neck dissection alone, but T4 lesions may require bilateral neck
dissection when involvement of the medial wall of the pyriform sinus or
postcricoid mucosa is suspected. Tumors that involve the medial wall of
the pyriform sinus have a higher incidence of regional failure in the
contralateral neck compared with lateral wall lesions, and require bilateral
neck dissection [6]. Bilateral zone VI dissections are rarely performed
because of the risk of postoperative hypocalcemia [7].
Results
Limited data exist regarding the results of surgical treatment alone,
because the combination of surgery and postoperative radiation therapy has
become the standard of care for all but very small primary lesions with
negative margins and no histologic evidence of nodal metastases [7].
Postoperative radiation therapy is superior to preoperative radiation
therapy, with better locoregional control and fewer surgical complications,
and avoids the loss of important prognostic information obtained from
a nonirradiated surgical specimen [45]. Most patients who have hypophar-
yngeal cancer have histologic indications for adjuvant postoperative
radiation therapy, such as perineural invasion, lymphovascular invasion,
more than two lymph nodes with metastatic disease, extracapsular spread,
or close or positive margins. For most patients, surgery alone does not
provide sufficient disease control. Retrospective reviews comparing surgical
treatment alone with surgery plus postoperative radiation therapy have
shown decreased locoregional recurrence rates (11%–14% versus 39%–
57%, respectively) and improved 5-year disease-specific survival rates
(40%–48% versus 18%–25%, respectively) with the addition of post-
operative radiation therapy [8,46].
Surgery with postoperative radiation therapy is associated with local
recurrence rates of 4% to 18% and regional recurrence rates of 17% to 47%
[3,6,7,11,46]. Locoregional recurrence has been reported to be higher in
patients with postcricoid lesions compared with those who have lesions in
other sites [2]. No significant difference has been shown in local or regional
control rates between pyriform lesions and posterior wall lesions, with the
exception that T4 lesions of the posterior wall seem to have a higher
incidence of local recurrence when compared with lateral lesions, probably
because of prevertebral muscle involvement [23]. Within subsites, medial
wall pyriform sinus lesions have a higher incidence of failure in the
contralateral neck when compared with lateral pyriform lesions but have
equivalent local and regional recurrence rates [6].
Advanced-stage neck disease is significantly associated with increased
locoregional recurrence rates and poorer 5-year disease-specific survival
rates. N2 or N3 neck disease is associated with 5-year disease-specific
survival rates of 0% to 20% compared with 28% to 57% in patients with N0
or N1 disease [3,7]. The presence of extracapsular spread is associated with
92 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
poorer survival rates among patients with nodal disease [8]. In patients with
indications for elective treatment of the neck, the combination of surgery
and radiation therapy seems to result in better regional control rates
compared with reliance on postoperative radiation therapy alone to sterilize
N0 neck disease [6,7]. In patients who have clinically staged N0 disease, the
presence of occult metastatic disease results in poorer 5-year disease-specific
survival rates compared with patients who have N0 disease without occult
nodal disease (32% versus 50%, respectively) [7].
Surgical resection results in loss of the larynx in 56% to 79% of patients
and pharyngoesophagectomy in 27% to 44% of patients [2,7,10,27,47].
These numbers have driven the search for effective organ-sparing methods
of treatment.
indicated for residual neck disease and for patients with N2 and N3 neck
disease who seem to have had a complete response to treatment [57].
Several nonrandomized studies have reported that hyperfractionated
radiation therapy provides a 15% to 25% improvement in local control
rates for larger tumors [9,23,27]. It has been suggested that doses of 7680 to
7920 cGy administered by twice-daily fractionation are required to
demonstrate benefit: the larynx must be shielded at doses greater than
7440 cGy to prevent laryngeal complications from treatment [23]. There is
an increased incidence of treatment-related complications on this schedule
when compared with conventional radiation therapy and these seem to be
dose related [9,23]. Hyperfractionated radiation therapy seems to improve
local control rates but incurs socioeconomic and time constraints and does
not seem to result in improved survival when compared with conventional
radiation therapy [9,23]. Prospective randomized studies are needed to
separate out selection bias to determine the efficacy of radiation therapy
alone in patients who have hypopharyngeal cancer compared with other
modalities of therapy.
Chemoradiation therapy
Chemotherapy sometimes yields impressive initial tumor responses, but it
is not a curative modality and does not improve survival rates in patients
who have head and neck cancer. Multiple chemotherapeutic agents have
been tried in combination with surgical therapy or radiation therapy. The
response of SCC to cisplatin, particularly in combination with 5-fluorouracil
(5-FU), has resulted in more widespread interest in chemotherapy as
adjunctive treatment. Patients who respond to chemotherapy show a sub-
sequent response to definitive radiation therapy, suggesting that tumors that
are sensitive to chemotherapy are radiosensitive. Induction chemotherapy
consists of the administration of two or three cycles of chemotherapy
initially, to distinguish between responders who are likely to benefit from
radiation therapy and nonresponders who are more likely to fail and require
surgery. In 1990, the use of chemoradiation for organ preservation
was established by the Department of Veterans Affairs Laryngeal Cancer
Study Group in a landmark prospective randomized trial [58]. Induction
chemotherapy with cisplatin and 5-FU, followed by definitive full-course
radiation therapy in responders, resulted in larynx preservation in two thirds
of patients who otherwise would have required total laryngectomy, without
compromising survival. These findings resulted in the acceptance of organ
preservation therapy in the treatment of laryngeal cancer and have led to
interest in determining whether these findings hold true for other sites in the
head and neck.
The only randomized, prospective phase 3 trial to date investigating
chemoradiation in patients who have hypopharyngeal cancer was conducted
by the EORTC Head and Neck Cancer Cooperative Group [29]. Patients
94 C.G. Gourin, D.J. Terris / Surg Oncol Clin N Am 13 (2004) 81–98
Summary
Despite advances in surgical and nonsurgical treatment, overall survival
rates for patients who have hypopharyngeal carcinoma have not improved,
and this disease still has a poor prognosis. The best results are obtained with
multimodality therapy, but at best, two thirds of patients are palliated rather
than cured of disease. Radical surgery with postoperative radiation therapy
remains the standard of care. Organ preservation strategies have not been as
successful in hypopharyngeal cancer as for cancers of other head and neck
sites. Chemoradiation is an effective alternative method of aggressive
treatment but may be associated with significant dysfunction of the end
organ when preservation is possible. Because of poor long-term survival
rates, local control remains the most important factor in planning
treatment, to provide meaningful palliation and best possible quality of life.
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* Corresponding author.
E-mail address: pablo.mojica@roswellpark.org (P. Mojica-Manosa).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00130-3
100 P. Mojica-Manosa et al / Surg Oncol Clin N Am 13 (2004) 99–112
Anatomy
The larynx is divided anatomically and clinically into three areas: supra-
glottic, glottic, and subglottic. This section describes how the anatomy re-
lates to cancer origin and spread. Treatment options are often based on
the anatomic site of laryngeal cancer.
Larynx
The supraglottic larynx extends from the epiglottis down to the lateral
angle of the ventricles. This includes the epiglottis, pre-epiglottic space, the
hyoid bone and arytenoids cartilage mucosa. The supraglottis is derived
from midline wedge-shape structures and ultimately has bilateral blood
supply and lymphatic drainage.
The hyoid bone is the most superior structure of the supraglottic larynx.
It is the point of attachment of numerous muscles and ligaments. It is
composed of the greater cornu laterally and lesser cornu medially.
The epiglottis is composed of elastic cartilage. It is widest at the top and
tapers down to the petiole. There is a suprahyoid, infrahyoid, and petiole
portion. The suprahyoid portion is covered by mucosa in both sides. The
infrahyoid portion is covered by mucosa posteriorly and abuts the fat of
the preepiglottic space anteriorly. It is a fenestrated structure that pro-
vides a pathway for the extension of normal structures like lymphatics,
submucosal glands, blood vessels, and nerves. In addition, these perfo-
rations provide a route of spread for supraglottic carcinoma from the mu-
cosa to the pre-epiglottic space [9]. The most inferior aspect is the petiole,
which is attached to the thyroid cartilage by way of the thyroepiglottic
ligament. The hyoepiglottic ligament is the roof of both the paraepiglottic
and preepiglottic spaces. It provides a formidable barrier for carcinoma
invasion to the base of the tongue [9].
The pre-epiglottic space is surrounded by the hyoepiglottic membrane
superiorly, the epliglottis posteriorly, the thyrohyoid membrane anteriorly,
and the thyroepiglottic ligament inferiorly. This space is continuous laterally
with the para-epiglottic space. This space is bounded anterolaterally with
the thyroid cartilage and thyrohyoid membrane and medially with the quad-
rangular membrane. These spaces are important because they provide the
route for superior and inferior spread in the larynx [9].
The glottic larynx extends from the lateral angle of the ventricle down to
one centimeter below the apex of the ventricles. It contains the true vocal
cords, the posterior and anterior commissure. It arises from lateral cell masses
that come together, and the lymphatic drainage tends to be ipsilateral.
P. Mojica-Manosa et al / Surg Oncol Clin N Am 13 (2004) 99–112 101
The lamina propia of the true vocal cords has a superficial layer com-
posed of loose fibrous tissues that makes up Reinke’s space. An interme-
diate and deep layer consisting of elastic and collagenous fibers forms the
vocal ligament. Blood vessels and lymphatics are almost absent in this space,
which creates resistance to tumor invasion [9].
The true vocal cords meet anteriorly in the anterior commissure tendon,
which is attached to the thyroid cartilage. This area is devoid of peri-
chondrium, which is a pathway of less resistance to tumor progression. This
commisure extends superiorly from the thyroepliglottic ligament.
Another structure that makes tumor invasion more resistant is the conus
elasticus. This membrane extends from the true vocal cord down to the
upper border of the cricoid cartilage. The most anterior aspect is the crico-
thyroid membrane. This area contains the paraglottic space, which is a
pathway for tumor progression through the larynx [9].
The subglottic larynx extends from the bottom of the glottic to the inferior
aspect of the cricoid cartilage. It is a rare site for primary tumor origin, but is
more commonly associated with subglottic extension from the glottis. Because
of the proximity of the cricothyroid membrane and the rich postcricoid,
lymphatics have a higher propensity for extralaryngeal extension.
Diagnosis
The diagnosis of laryngeal cancer should be suspected when hoarseness
is present for more than 2 to 3 weeks. Tumors in the glottic usually present
early because of vocal cord involvement; tumors of the supraglottis usually
present later because of a lack of symptoms in the early stages. Other
symptoms associated with laryngeal tumors are hemoptysis, airway insuffi-
ciency upon exertion, halitosis, and the so-called ‘‘hot potato’’ voice. Dys-
phagia, airway compromise, stridor, and neck mass are more common in
advance disease.
Accurate examination by way of indirect or direct laryngoscopy is
of most importance to staging and treatment planning [30]. A critical
P. Mojica-Manosa et al / Surg Oncol Clin N Am 13 (2004) 99–112 103
Table 1
TNM staging of larynx carcinoma
Primary tumor (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Supraglottis
T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility
T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis, glottis,
or region outside the supraglottis (eg, mucosa of base of tongue, valleculla,
medial wall of pyriform sinus) without fixation of the larynx
T3 Tumor limited to larynx with vocal cord fixation or invades any of the following:
postcricoid area, pre-epiglottic tissues, paraglottic space, or minor thyroid
cartilage erosion (eg, inner cortex)
T4a Tumor invades through the thyroid cartilage or invades tissues beyond the larynx
(eg trachea, soft tissues of neck including deep extrinsic muscle of the tongue,
strap muscle, thyroid, or esophagus)
T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal
sturctures
Glottis
T1 Tumor limited to the vocal cords (may involve anterior or posterior commissure)
with normal vocal cord mobility
T1a Tumor limited to one vocal cord
T1b Tumor involves both vocal cords
T2 Tumor extends to supraglottis or subglottis, or there is impaired vocal cord mobility
T3 Tumor limited to the larynx with vocal cord fixation or invades paraglottic space,
or minor thyroid cartilage erosion (eg, inner cortex)
T4a Tumor invades through the thyroid cartilage or invades tissues beyond the
larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of
the tongue, strap muscles, thyroid, or esophagus)
T4b Tumor invades prevertebral space, encases carotid artery, or invades
mediastinal structures
Subglottis
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cords with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fixation
T4a Tumor invades through the thyroid cartilage or invades tissues beyond the
larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the
tongue, strap muscles, thyroid, or esophagus)
T4b Tumor invades prevertebral space, encases carotid artery, or invades mediastinal
structures
Regional lymph nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Single ipsilateral node, 3 cm or less in greatest dimension
N2a Single ipsilateral node, greater than 3 cm and less than 6 cm
N2b Multiple ipsilateral nodes less than 6 cm
N2c Bilateral or contralateral nodes less than 6 cm
N3 Metastasis in a lymph node more than 6 cm in greatest dimensions
(continued on next page)
104 P. Mojica-Manosa et al / Surg Oncol Clin N Am 13 (2004) 99–112
Table 1 (continued )
Distant metastasis (M)
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Data from the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original
and primary source for this information is the AJCC Cancer Staging Manual, 6th edition (2002)
published by Springer-Verlag New York (For more information, visit www.cancerstaging.net).
Any citation or quotation of this material must be credited to the AJCC as its primary source.
The inclusion of this information herein does not authorize any reuse or further distribution
without the expressed written permission of Springer Verlag New York, Inc., on behalf of the
AJCC.
Pathology
Only 1% of all laryngeal tumors are of the nonsquamous type. The most
common tumor types include cystic adenoid (adenocarcinoma), neuroen-
docrine, and carcinoid. Sarcomas have been reported, of which chondro-
sarcomas predominate. Other tumor types include pseudosarcoma, fibrous
histiocytoma, leiomyosarcoma, liposarcoma, synovial sarcoma, and giant
cell tumors. The vast majority of laryngeal tumors are squamous cell car-
cinomas. This article concentrates on the management of this type of tumor.
Treatment
Treatment of this type of tumor should focus on providing an ade-
quate oncologic chance of cure while attempting to minimize morbidity.
Important secondary goals of treatment include a serviceable voice and the
ability to swallow without aspiration.
Several factors may affect treatment. For example, exophytic tumors
tend to respond better to radiation than endophytic tumors, and poorly
differentiated tumors tend to metastasize more readily than well-differen-
tiated ones [36]. Tumor location and extent and the patient’s general medical
condition may also dictate the treatment option.
Supraglottic carcinoma
Treatment options for carcinoma of the supraglottis varies widely for
local control, cure rates, and 2- to 5-year survival rates for surgery, radia-
tion, or combination therapy, depending on the stage.
For early (T1, T2) tumors, surgery and radiation treatment are equivalent
in terms of locoregional control and survival. The control rates for surgery
and radiation in T1 tumors are 90% to 95% and 80% to 90%, respectively;
in T2 tumors, they are 80% to 90% and 70% to 80%, respectively [37–40].
Surgical salvage for radiation failure equalizes locoregional control for both
modalities.
It is important to consider the patient’s age and general medical condition.
The most common approaches to stage I and II are vertical partial laryng-
ectomy, supraglottic laryngectomy, supracricoid subtotal laryngectomy, and
total laryngectomy. The type of procedure is influenced by the site of the
tumor, extension, nodal status, and surgeon’s expertise. Although conserva-
tion surgery may be planned, is important to inform the patient that it may
ultimately change to a total laryngectomy if the tumor extension goes beyond
the previous examination studies.
Cure rates are lower for advanced tumors (T3, T4), with stage III at
40% and stage IV at 20% [8]. The mainstay of treatment for advanced supra-
glottic carcinoma is combination modality therapy that includes surgery
and radiation. Chemotherapy and radiation is an alternative that is under
106 P. Mojica-Manosa et al / Surg Oncol Clin N Am 13 (2004) 99–112
Glottic caricinoma
Locoregional control in glottic carcinoma differs from the supraglottic
carcinoma because of its embryology. Locoregional control after surgery or
radiation for T1 is 98% and 85% to 95%, respectively; for T2 it is 82% and
65% to 75%, respectively [8]. Treatment options will be affected by
decreased vocal cord mobility, anterior commissure involvement, subglottic
extension, and total size of the tumor. Vocal cord impairment will decrease
local control from 77% to 50% in 3 years, especially if both cords are
diseased. Radiation therapy is less effective with vocal cord mobility
impairment [42]. Anterior commissure invasion may change the T stage
from T1 to T4 in a few millimeters. Subglottic extension may increase
recurrence from 12% to 32% if extension is greater than 5 mm posteriorly
or 10 mm anteriorly [43].
For advanced glottic cancer (T3, T4), the local control rates for radiation
therapy range from 40% to 60%. Local control rates for surgery are greater,
ranging from 84% to 96%, and the 2-year disease-free survival is 79% for
T3 and 58% for T4 [8]. The ultimate decision to treat advanced glottic
carcinoma depends on the tumor specifics and the patient’s desires and
general medical condition. Combined modality therapy is considered supe-
rior to either surgery or radiation alone. Total laryngectomy is usually per-
formed, while near total laryngectomy or supracricoid laryngectomy may
be used in certain cases. Laryngeal preservation can be achieved with the
combination of chemotherapy and radiation 60% of the time [41].
Subglottic carcinoma
Primary subglottic carcinoma is rare. Most cases are a subglottic exten-
sion from glottic carcinoma. Involvement of the subglottic space increases
the risk of extralaryngeal spread. Treatment usually involves the combina-
tion of surgery and radiation therapy. It is recommended that surgery
include laryngectomy, thyroidectomy, and paratracheal node dissection.
Radiation therapy is recommended for advance cases. Elective neck dis-
section is recommended when the risk of cervical nodal metastases is greater
than 25%.
P. Mojica-Manosa et al / Surg Oncol Clin N Am 13 (2004) 99–112 107
For the supraglottis, the location of the tumor influences the incidence
of nodal metastasis. In the clinically negative neck, the risk of pathologic
metastatic node involvement ranges from 15% to 48% depending on the site
and size of the tumor [8]. For lesions in the marginal zone, the rate is higher
when compared with more centrally located tumors. One important aspect
of supraglottic carcinoma is the fact that as the tumor size increases, so does
the risk of bilateral neck spread. For T2 tumors, the risk of pathological
or clinically involved nodes is between 30% and 70%, with contralateral
disease occurring 50% of the time. With this in mind, it is recommended
that both sides of the neck be included in the treatment planning for tumors
T2 or higher, whether with surgery or radiation.
Because of the embryology of glottic carcinoma, the incidence of nodal
spread differs and the rate of contralateral disease is lower. Because the rate
of occult metastases for T1 and T2 lesions is between 1% to 8%, there is
little role for elective neck treatment [44,45]. The rate of occult disease is
approximately 15% for T3 and approximately 30% for T4 [46]. Elective
neck treatment in the form of surgery or radiation is recommended for T3
or T4 glottic lesions. Bilateral or contralateral disease will be seen with
subglottic and supraglottic extension of the tumor.
These nodal patterns support the removal of levels II, III, and IV in the
clinically negative neck. If there is extension beyond the subglottis, level IV
should be included in the dissection [47–49]. A comprehensive neck dis-
section should be performed for the clinically positive neck. For cases in
which there is pathologic node involvement of only one node, selective node
dissection can be adequate treatment.
Radiation can be considered for definitive treatment of cervical nodal
metastases in patients presenting with N0 or N1 disease [50]. Postoperative
radiation to the neck should be considered for patients who present with
multinodal disease or extracapsular spread [51].
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Surg Oncol Clin N Am 13 (2004) 113–127
Salivary gland tumors represent 3% of head and neck tumors and 0.6%
of all tumors in the body. Parotid gland tumors constitute 70% to 80% of
tumors of the salivary gland, and 20% of parotid gland tumors are
malignant. Four fifths of the parenchyma of the gland lies lateral to the
facial nerve, in the superficial lobe, and 90% of parotid neoplasms present in
the superficial lobe. Approximately 80% of parotid tumors occur in the
lower part of the gland. Parotid pleomorphic adenoma is the most common
parotid neoplasm, accounting for 60% to 70% of parotid tumors.
Malignant salivary gland tumors have an incidence of less than 1 per
100,000 individuals. Most malignant salivary gland tumors arise from the
excretory or intercalated duct reserve cells [1]. Their origin is largely
unknown. Genetic alterations, including allelic loss, chromosomal trans-
locations, and absence or addition of a chromosome, may be factors in some
cases. A heightened risk after radiation exposure [2] is not uniformly
reported [3]. Malignant parotid tumors are slightly more common in
women, with a peak incidence in the fifth through seventh decades of life.
Malignant salivary gland tumors generally present as painless, slow-
growing tumors that are indistinguishable from benign tumors. The overall
detection rate for salivary gland malignancy based on clinical features is
approximately 30%; palpable cervical lymph nodes, facial nerve palsy, and
deep fixation and rapid enlargement of the tumor are significant parameters
for parotid gland tumors [4]. Both benign and malignant tumors can present
with pain in a small percentage of patients. Approximately 10% of patients
who have parotid gland malignancies present with facial paralysis, which is
associated with a poor prognosis. Patients who have deep-lobe parotid
tumors may present with distortion of the lateral pharyngeal wall on intraoral
examination. Trismus may represent infratemporal fossa involvement.
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00126-1
114 R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127
a Warthin’s tumor, FNA may obviate the need for surgery. In addition, the
use of FNA may avoid parotid gland surgery in sarcoidosis, tuberculosis,
histoplasmosis, lymphoma, and benign cervical adenopathy in patients with
HIV and in children. FNA can distinguish an upper cervical neck mass from
a low tail of parotid tumor. It also is helpful in patients who have
116 R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127
Mucoepidermoid carcinoma
Mucoepidermoid carcinoma is the most common malignant tumor of the
parotid gland and the second most common malignant tumor of the
Fig. 2. Photomicrograph of the cribriform type of adenoid cystic carcinoma demonstrating the
‘‘Swiss cheese’’ appearance (magnification 100 with H&E stain). Arrows show pseudolumens
that are in continuity with the stroma of the tumor. (From Ellis GL, Auclair PL. Tumors of the
salivary gland. In: Rosai J, editor. Atlas of tumor pathology. Washington, DC: Armed Forces
Institute of Pathology; 1996. p. 206; with permission.)
R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127 119
margin, and previous radiation therapy. The 10-year survival rates for the
solid and cribriform subtypes have been reported as 0% and 62%,
respectively [9]. Many patients survive for several years after recurrence,
but up to 80% ultimately succumb to this malignancy.
Fig. 3. Photomicrograph of acinic cell carcinoma (magnification 200 with H&E stain). (From
Ellis GL, Auclair PL. Tumors of the salivary gland. In: Rosai J, editor. Atlas of tumor pathology.
Washington, DC: Armed Forces Institute of Pathology; 1996. p. 186; with permission.)
120 R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127
Melanoma
Most malignant melanomas arise from cutaneous primary sites, with the
parotid gland being a frequent metastatic location. The prognosis is
generally poor. Mucosal and ocular primary sites also must be considered.
122 R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127
Lymphoma
Lymphoma of the parotid gland represents 1% to 2% of parotid
malignancy presenting either primarily or as part of disseminated disease.
The incidence is equal in men and women, and this tumor rarely occurs before
the age of 50. Patients with Sjögren’s syndrome have a 40-fold greater risk for
a parotid lymphoma than the general population. Most are B-cell, non-
Hodgkin’s lymphomas, with 80% of patients presenting in stage I or II disease
[18]. Primary lymphomas are usually low grade; however, even intermediate-
and high-grade lymphomas of the parotid gland can have a satisfactory
prognosis with chemotherapy and radiation therapy. Immunohistochemical
analysis can help differentiate the low-grade mucosa-associated lymphoid
tissue lymphoma from myoepithelial sialadenitis. In many cases, lymphoma
can be diagnosed with FNA using immunohistochemistry.
Undifferentiated carcinoma
Undifferentiated carcinomas include large cell undifferentiated carci-
noma, small cell undifferentiated carcinoma, and lymphoepithelial carci-
noma. Primary lymphoepithelial carcinoma may arise from a benign epithelial
lesion. It has been reported in Asians and Greenland Eskimos, with an
associated Epstein-Barr virus infection [19].
Molecular biology
DNA flow cytometry can assist in the characterization and diagnosis of
salivary gland malignancies, which can be difficult to diagnose. Bang et al
[20] reported that 43% of salivary gland tumors were reclassified after DNA
R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127 123
Treatment
Salivary gland surgery
Surgery is the primary treatment for salivary gland malignancy. The
minimal operation for a parotid mass is superficial parotidectomy with facial
nerve dissection. Enucleation will result in higher rates of recurrence and facial
nerve dysfunction. Low-grade parotid tumors may be treated with superficial
parotidectomy. Facial nerve monitoring for a mobile tumor of the superficial
lobe will not decrease the rate of facial nerve dysfunction [24]. Deep-lobe
tumors, facial nerve dysfunction, recurrent tumors, fixed tumors, tumors
larger than 4 cm, and nodal metastasis are indications for nerve monitoring.
The incision in the preauricular skin curves gently 2 mm below the ear
lobule to prevent distortion of the ear lobule, and subsequently 3 cm below
the mandible so as not to traumatize the marginal mandibular branch of the
facial nerve. Electrosurgical dissection is eschewed. The sternocleidomastoid
muscle is separated from the parotid gland. The facial nerve trunk
emanating from the stylomastoid foramen is superior to the cephalic
margin of the digastric muscle. The cartilaginous tragal pointer leads to the
tympanomastoid suture. The pes anserinus of the facial nerve is invariably
located 2 mm to 4 mm inferior to this most important anatomic landmark.
Facial nerve dissection can be performed atraumatically with a fine
hemostat, bipolar coagulation, and plastic scissors. Bipolar scissors, the
harmonic scalpel, and hemostat/stimulator probes with a dedicated nerve
monitor have been advocated.
Deep-lobe dissection or total parotidectomy is indicated for deep-lobe
tumors, superficial tumors that extend to the deep lobe, high-grade tumors,
and tumors involving the parapharyngeal space. After completion of the
superficial parotidectomy, the facial nerve branches are elevated from
surrounding parotid tissue or tumor, and the deep lobe is separated from the
124 R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127
Neck dissection
Neck metastases are present in 10% to 20% of parotid gland
malignancies. These generally occur in levels II and III. The survival rate
R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127 125
Radiation therapy
Patients who have advanced-stage disease, positive margins, nodal me-
tastasis, preoperative facial nerve dysfunction, and high-grade tumors are
candidates for postoperative radiation therapy. Combined therapy with
surgery followed by radiation therapy has resulted in improved 5-year
disease-free survival rates as high as 77%, with few sequelae from radiation
[27]. Retrospective reviews have not defined a radiation dose–response
relationship, and treatment has ranged from 50 to 70 Gy. Radiation therapy
as the primary treatment may be appropriate for patients with unresectable
tumors or those with overwhelming comorbidities. Postoperative radiation
therapy for patients with positive surgical margins was reported to be
effective for T1 and T2 disease but not for advanced-stage disease [28].
Chemotherapy or combined radiation therapy and chemotherapy have not
improved survival (excluding lymphoma), although chemotherapy has been
used in palliative settings.
Recurrence
The pattern of recurrence for most parotid gland malignancies, in order
of frequency, is local recurrence, cervical neck metastasis, and distant
metastasis [26]. Significant factors for survival are as follows: advanced age,
tumor stage, positive nodal disease, facial nerve involvement, high-grade
tumors, extraparenchymal spread, and positive margins.
126 R.L. Witt / Surg Oncol Clin N Am 13 (2004) 113–127
Summary
Major salivary gland cancers are rare, with many histologic types and
subtypes. The tumor stage at presentation will dictate the need for imaging,
FNA, and facial nerve monitoring. Immunohistochemistry has enhanced
diagnosis. In addition, precise attention to surgical landmarks and technique
will reduce complications. Tumor stage, histologic type, tumor grade,
surgical margin, facial nerve dysfunction, perineural involvement, extra-
parenchymal spread, and nodal metastasis are factors influencing the indi-
cation for neck dissection, postoperative radiation therapy, and survival rate.
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Surg Oncol Clin N Am 13 (2004) 129–149
* Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263.
E-mail address: dominick.lamonica@roswellpark.org
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00129-7
130 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
Fig. 1. Mayo Clinic patients with papillary carcinoma judged to be at high (25%–40%) or low
(1%–2%) risk for mortality using EORTC (upper left), UICC (upper right), AGES (lower left),
and AMES (lower right) classification systems. (From Hay ID. Papillary thyroid carcinoma.
J Endocrinol Metab Clin North Am 1990;19:561; with permission.)
rate, 88%–90%) versus high (survival rate,\10%) risk from follicular tumors
in a system incorporating age and the presence of vascular invasion and
distant metastases at diagnosis [9]. Although follicular carcinomas are
typically smaller when discovered, they are usually found later in life and are
more advanced, with a propensity for hematogenous dissemination and
distant metastasis. Survival statistics for equally staged papillary tumors are
also poor. A recent large-scale retrospective analysis comprising patients
from the Ohio State University (OSU) and US Air Force (USAF) who had
both papillary and follicular cancers focused principally on tumor-specific
factors associated with disease recurrence and cancer-specific mortality [10].
As a part of this study, tumor variables alone were used in a system for the
clinical staging of thyroid malignancies. In addition to age at diagnosis and, to
a lesser degree, patient gender, tumor features, such as size, extrathyroidal
extension, multifocality, and the presence of distant metastases were all
shown to affect outcomes. From a clinical standpoint, all of the previously
mentioned factors warrant review at the time of initial consultation. From
a nuclear medicine perspective, we believe that it is most important to base
decisions regarding adjuvant 131I therapy on anatomic staging at the time of
diagnosis.
Fig. 2. Recurrence and cancer death based on age at diagnosis. (From Mazzaferri EL, Jhiang
SM. Long-term impact of initial surgical and medical therapy on papillary and follicular cancer.
Am J Med 1994;97:422.)
132 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
Fig. 3. Recurrence and cancer death based on time from initial diagnosis. (From Mazzaferri
EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and
follicular cancer. Am J Med 1994;97:421.)
Table 1
Risk stratification systems for differentiated thyroid carcinoma
Recognized risk factors
Scoring system Patient-specific Tumor-specific
United States
AMES [7] (Lahey Clinic) Age Metastasesa, extentb, sizec
AGES [6] (Mayo Clinic) Age Graded, extent, size
MACIS [23] (Mayo Clinic) Age, completeness Metastases, extent (invasion
of resection beyond gland), size
University of Chicago [16] — Metastases, lymph node statuse,
extent
OSU/USA [10] — Metastases, lymph node status,
extent, size
MSKCC [17] Age Metastases, extent, size
AJCC [18] Age Metastases, extent, size
Europe
EORTC [4] Age, sex Metastases, lymph node status,
cell typef, extent
UICC [5] Age Metastases, extent, size
Abbreviations: AJCC, American Joint Committee on Cancer; MACIS, Metastases, Age,
Completeness of resection, Invasion, Size.
a
Metastases, distant tumor in sites outside of neck (ie, lung, bone, brain).
b
Extent invasion, extension of tumor to extrathyroidal soft tissues.
c
Size, size of primary tumor.
d
Grade, histologic grade of primary tumor.
e
Lymph node status, tumor-positive cervical lymph nodes.
f
Cell type, medullary, poorly differentiated follicular, anaplastic, all other.
134 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
131
Postsurgical I remnant ablation
When the surgical team intends to perform total or near-total
thyroidectomy, patients are typically referred for a postoperative 131I scan
for assessment for remnant thyroid tissue and adjuvant administration of
radioactive iodine. Total resection of the thyroid is a difficult proposition,
and attention to critical structures within the neck usually interferes with
complete surgical removal of glandular tissues. The term ‘‘radioiodine
ablation’’ refers to the use of 131INa to destroy what is presumed to be
normal thyroid tissue remaining within the neck following operation. The
current author has found that more than 90% of patients referred for
radioiodine scan in the weeks following surgery show uptake within the neck
indicative of some thyroid remnant. Radioiodine ablation of residual
thyroid tissue in the setting of intermediate-stage tumor is advised for the
following reasons:
1. It has been shown to reduce the risk of tumor recurrence and thereby
lessen the chances of adverse outcome relating to treatment failure [10,30].
2. It clearly increases the sensitivity of diagnostic 131I scans and the efficacy
of further 131I treatments. DTC is typically less iodine-avid than is the
D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149 135
131
I therapy of differentiated thyroid carcinoma
The approach to radioiodine therapy of metastases from DTC varies in
many clinics within the United States. The demonstration of iodine-
concentrating tumor outside the operative bed on preablation 131I imaging
often calls for an increase in the 131I doses typically used for the ablation of
normal postsurgical thyroid remnant. Persistent or recurrent tumor seen on
136 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
131
Acute and long-term effects of I therapy
Early effects
Although 131I is lethal to the cells most able to concentrate it, it is not
without immediate and long-term effects on background tissues free of
disease.
Mild, acute radiation symptoms have been described in the immediate
post-treatment period in close to two thirds of patients receiving 131I therapy
[39,40]. These symptoms are usually reported for doses in excess of 5550 MBq
(150 mCi), and this post-treatment period is often marked by fatigue, loss of
138 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
131
Late effects of I treatment
Although most of the immediate effects described previously resolve
during the weeks following 131I therapy, the chances of long-term organ or
tissue injury increase with the cumulative dose of radioactivity required for
treatment.
Female reproductive function is usually unaffected by single admin-
istrations of 131I. Permanent reproductive organ impairment may result
from repeated therapies for this disease, however. One study noted that the
miscarriage rate after 131I ablation that used doses in excess of 100 mCi was
nearly double the increase observed following thyroidectomy alone [50]. The
reasons for this finding are not entirely clear, although this observation
suggests a possible relation to irradiation of the ovaries. It seems that there
is no increase in risk of birth defects from treatment of children or women of
childbearing age. This same study of women and pregnancy before and after
131
I therapy for thyroid carcinoma revealed no evidence for increased risk of
congenital malformation, stillbirth, or prematurity following treatment of
this disease. Long-term studies suggest that fertility is unaffected for women
younger than 30 years at the time of therapy [51]. Such statistics are usually
directly correlated to cumulative radiation dose, however. Although
permanent sterility has not been recorded for premenopausal women
receiving less than 11,100 MBq (300 mCi) of 131I, it has been reported in
nearly 60% of women receiving 131I doses in excess of 29,600 MBq (800
mCi) [10,52]. Patients should be aware of this finding. Women treated in the
current author’s clinic are advised to avoid pregnancy during the 12 months
following 131I therapy.
A different situation exists for men undergoing 131I therapy for thyroid
cancer, because the testes are especially vulnerable to the effects of radiation.
A single 131I treatment involving only moderate doses of radioiodine (1850–
3700 MBq [50–100 mCi]) is sufficient to cause reduction in sperm count [53].
The testicular effects described from 131I therapy in men are proportional to
140 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
the total dose of radioactivity received over the course of treatment [54].
Permanent sterility has been described in men receiving cumulative doses
greater than 29,600 MBq (800 mCi) [55]. Sperm banking should be
considered for young men who have extensive disease.
Lung fibrosis is often a concern for physicians treating patients who have
diffuse pulmonary spread of iodine-avid thyroid tumor; however, it is
uncommon. Lung fibrosis was originally reported in the early experience of
the MSKCC group [32]. Based on five events in 59 patients, dosimetry
guidelines were adjusted to ensure retained activities were kept under 4440
MBq (120 mCi) at 48 hours in all patients and under 2960 MBq (80 mCi) at
48 hours in those who had diffuse lung metastases [56]. It is the current
author’s experience that, on average, 30% to 50% of the administered 131I
dose is excreted within 24 hours in athyrotic patients who have normal renal
function. Exceptions to this are patients with large thyroid remnants or
those with an overwhelming mass of persistent, functioning tumor. The
standard fixed-schedule dose of 7400 MBq (200 mCi) usually advocated for
treatment of lung metastases is therefore safe for treatment of pulmonary
disease in the overwhelming majority of patients. An approach that uses
dosimetry would safely permit the upfront augmentation of therapy, which
is particularly needed for disease outside the neck. It would also be recom-
mended in therapies for those patients who have compromised renal function.
Radiation-induced malignancy is probably the most serious among the
potential late effects of 131I treatment. Permanent count reductions and white
cell and platelet abnormalities are sometimes seen in patients receiving more
than 37 GBq of 131I for treatment of thyroid cancers. A large-scale meta-
analysis comprising 13 series and 2753 patients reported a slight increase in
prevalence of acute myelogenous leukemia (AML) for patients who had
received 131I therapy for thyroid cancer [57]. Many of the patients received
high doses of radioiodine over short time intervals, a fact that only enhances
the mutagenic properties of ionizing radiation for both normal and diseased
tissues. A small increase in deaths from bladder cancer and leukemia has
been reported with cumulative 131I doses in excess of 37 GBq [51]. Again, the
risk is proportional to cumulative dose of radioactivity and underscores the
need for attention to bowel and bladder function in the days following
therapy. In view of these effects, 131I treatments are normally spaced at 12-
month intervals and are usually not repeated any sooner than 6 months for
the more aggressive tumor variants. Placed in perspective, the lifetime risk of
leukemia is small enough so that, even with the added radiation exposure
from 131I treatment, this risk does not exceed the risk of dying from
metastatic thyroid cancer [2].
131
I imaging and follow-up
Following radioiodine ablation of thyroid remnant or treatment of
iodine-concentrating thyroid tumor, the current author recommends
D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149 141
131
I therapy of differentiated thyroid carcinoma: outcomes
A beneficial effect has been demonstrated from the use of 131I for the
postoperative ablation of thyroid remnant in patients at intermediate risk
for disease recurrence [10,30]. Patients who have disease outside the neck
who respond to 131I therapy have significantly longer survival times than
those who do not [11]. There can be considerable impact for the 131I
treatment of distant metastases within the lung. The 10-year survival rate for
patients treated with 131I for lung metastases evident only on post-treatment
whole body survey has been reported to be 100%. The numbers are lower
but still impressive for disease seen either on pretherapy 131I imaging alone
(91%) and/or with an accompanying micronodular pattern on radiographic
study (63%) [64]. Macronodular lung tumor is considerably more difficult to
treat with 131I, and bone metastases represent an even greater challenge.
Dominant or solitary skeletal sites optimally require a multidisciplinary
team approach centering on surgery or external beam radiotherapy [65].
Here as well, however, 131I can have a role for the treatment of residual
disease (Fig. 4). A similar application for 131I is anticipated for rare
individuals with isolated CNS lesions [66].
Further management
L-thyroxine therapy
Following surgery and initial radioiodine therapy for DTC, patients are
begun on T4 replacement and enter a regular schedule of clinical follow-up
based largely on surgical findings and results of post-therapy imaging.
D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149 143
Fig. 4. (A) Skeletal metastases (arrowheads) from papillary thyroid carcinoma on initial
postoperative 131I scan. (B) Positive post-treatment images 1 week after 131I therapy. (C)
Negative follow-up 131I images 1 year post therapy.
144 D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149
Fig. 4 (continued)
Studies have suggested that the recurrence rate of DTC is reduced by the
augmented administration of T4. The degree of TSH suppression required
remains controversial, however. A retrospective European investigation
showed degree of TSH suppression as an independent predictor of disease
recurrence [67]. A more recent prospective study in the United States,
however, reported that, when it was measured against other variables, the
degree of TSH suppression taken alone did not predict those individuals at
greater risk for recurrent disease [68]. Despite ongoing debate, it is
recommended that intermediate-stage patients be started on a dose of T4
sufficient to maintain serum TSH levels just below the lower limit of the
normal range 0.1–0.4 micro-International Units per mililiter (uIU/mL) [69].
If there is documentation of residual neck disease or distant metastatic
D. Lamonica / Surg Oncol Clin N Am 13 (2004) 129–149 145
Moreover, rhTSH is a welcome and necessary option for those who cannot
mount a TSH response to hormone withdrawal (ie, functioning tumor,
pituitary insufficiency) and a needed, although as yet unproven, alternative
for treatment of patients unable to tolerate the prolonged effects of
profound hypothyroidism (ie, CNS critical lesions, cardiac insufficiency). A
situation that would not allow use of this dual approach using rhTSH
imaging and Tg would be the patient with autoantibodies to Tg, because
these would likely invalidate the added information obtained with this
laboratory assay.
Summary
The importance of the optimization of the upfront management of DTC
cannot be underestimated. An aggressive approach is advocated, except in
situations widely accepted to be low risk (ie, female patients \40 y, with
tumors \1.0 cm confined to the gland). Distant tumor greatly reduces the
chances for survival in all patients. The loss of iodine-concentrating ability
removes systemic radioiodine from the therapeutic equation and thereby
virtually eliminates chances for cure. The role of chemotherapy in noniodine
responsive DTC is still in question, and a benefit in advanced disease has not
been established. For non–iodine-concentrating tumor that cannot be
approached surgically, external beam therapy remains an option, both
within the neck and for dominant foci of distant metastatic tumor (ie, brain
and bone). Any distant lesion demonstrating the capacity for radioiodine
uptake also should be addressed with 131I, because this will potentially treat
tumor not evident on diagnostic survey.
In conclusion, 131I has demonstrated efficacy for the postsurgical
management of DTC. Although its acute and long-term side-effect profile
is not especially worrisome relative to other forms of systemic cancer
therapy, the administration of 131I is not entirely without risk. Taking into
account many of the issues described in this article, the administration of
131
I should in every case be optimized. It also should be applied carefully
and judiciously to patients expected to derive benefit.
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Surg Oncol Clin N Am 13 (2004) 151–166
1
Current address: Department of Surgery, St. Paul’s Hospital, 1081 Burrard Street,
Vancouver, British Columbia, Canada, V6Z 1Y6.
* Corresponding author.
E-mail address: nestor.rigual@roswellpark.org (N.R. Rigual).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00119-4
152 N.R. Rigual, S.M. Wiseman / Surg Oncol Clin N Am 13 (2004) 151–166
Fig. 1. The levels of the neck. (Drawing by Paul Tomljanovich, MD, medical illustrator.)
Fig. 2. The sublevels of the neck. (Drawing by Paul Tomljanovich, MD, medical illustrator.)
mylohyoid muscle and above the hyoid bone but are posterior and lateral to
the anterior belly of the digastric muscles and anterior to the posterior
border of the submandibular gland. Level II nodes are contained in the
space defined superiorly by the skull base, inferiorly by the hyoid bone,
anteriorly by the posterior border of the submandibular gland, and
posterior to a transverse line drawn on each axial image through the
posterior edge of the SCM. The deep border of level II is defined by the
internal carotid artery in that any nodes lying medially to this vessel are
considered to belong to the retropharyngeal nodal group. Level III nodes
are located between the lower border of the hyoid bone and the lower
margin of the cricoid cartilage. These nodes lie laterally to the common
carotid artery. On both sides of the neck, the medial margin of the carotid
arteries separates the level III nodes, which are located laterally to level IV
nodes, which lie medially to the vessels. Level IV nodes lie inferiorly to the
lower border of the cricoid cartilage and superiorly to the clavicle. The
boundaries of levels V and VI are the same as in the clinical classification.
Fig. 3. Radical neck dissection. (Drawing by Paul Tomljanovich, MD, medical illustrator.)
N.R. Rigual, S.M. Wiseman / Surg Oncol Clin N Am 13 (2004) 151–166 157
more lymph node levels are preserved. The lymph node levels removed
are based on the location of the primary tumor because the clinical
patterns of cervical lymphatic metastasis from head and neck tumors have
been shown to be predictable in multiple, large-scale, retrospective studies
[8,14,15].
The lymph nodes at risk for laryngeal, hypopharyngeal, and oropharyn-
geal carcinomas are usually found within levels II, III, and IV. For thyroid
cancer and subglottic cancers, the nodes in level VI are at greatest risk of
harboring metastatic disease. Lymph nodes in levels I, II, and III are at
greatest risk of harboring microscopic metastatic disease in patients who
have oral cavity primary cancers. Skip metastasis to level IV may potentially
represent a problem in patients who have oral tongue carcinoma [16].
The most significant paradigm shift in the management of cervical lymph
node disease over the past decade has been the selective removal of lymph
node groups that are at greatest risk of harboring metastases. Although this
change in treatment philosophy has been applied mostly to patients with N0
nodal disease, SND also has a role in the treatment of N-positive neck
tumors [17,18].
Fig. 4. Selective neck dissection II–IV. (Drawing by Paul Tomljanovich, MD, medical
illustrator.)
Fig. 5. Selective neck dissection I–III. (Drawing by Paul Tomljanovich, MD, medical
illustrator.)
Fig. 6. Selective neck dissection I–IV for oral tongue cancer. (Drawing by Paul Tomljanovich,
MD, medical illustrator.)
160 N.R. Rigual, S.M. Wiseman / Surg Oncol Clin N Am 13 (2004) 151–166
nodes adjacent to the recurrent laryngeal nerves [7]. The superior boundary
of the dissection is the body of the hyoid bone, and the inferior margin is the
suprasternal notch. The lateral margins are defined by the common carotid
arteries. SND VI is most commonly indicated in the treatment of thyroid
cancer, advanced laryngeal cancer with subglottic extension, and cervical
esophageal carcinoma (Fig. 7). In thyroid cancer where there is clinical
evidence of nodal metastases in the neck, either preoperatively or
intraoperatively, the procedure of choice also would include levels II to V,
and is designated SND II–VI.
Fig. 7. Selective neck dissection VI, or central compartment neck dissection. (Drawing by Paul
Tomljanovich, MD, medical illustrator.)
N.R. Rigual, S.M. Wiseman / Surg Oncol Clin N Am 13 (2004) 151–166 161
Fig. 8. Extended neck dissection (common carotid artery, digastric muscle, hypoglossal nerve).
(Drawing by Paul Tomljanovich, MD, medical illustrator.)
Sentinel lymph node biopsy: a new paradigm for staging N0 neck tumors
Sentinel lymph node biopsy (SLNBX) has become an accepted technique
for staging the first extratumoral echelon of draining lymph nodes in
individuals diagnosed with melanoma or breast cancer. Similar to SND,
SLNBX is based on the principle that lymphatic metastases do not occur in
a random manner, but rather predictably, in accordance with preexisting
lymphatic anatomy. As discussed, the practice of Staging SND, performed
162 N.R. Rigual, S.M. Wiseman / Surg Oncol Clin N Am 13 (2004) 151–166
stage N0 oral cavity head and neck cancer. Although SLNBX was
technically feasible, and no adverse effects were observed in the authors’
patient population, the sentinel node identification rate was only 57%, and
when identified, the sentinel node accurately predicted the pathologic status
of the neck in 75% of patients. The negative predictive value for the absence
of cervical metastases was 67% [31]. The authors’ experience was similar
to that of other investigators who found that a vital dye technique alone
had a low rate of sentinel node identification (0%–67%), and even when
identified, the sentinel node often did not accurately predict the pathologic
status of the neck (0%–75%) [32,33]. The poor clinical utility of the vital
dye methodology is a sharp contrast to the high rate of sentinel node
identification reported when a radiotracer technique is used (in most series,
100% of sentinel nodes were identified) [34–44]. In addition, using the
radiotracer technique, the sentinel node almost always accurately reflected
the pathologic status of the neck. Other investigators have used a combined
vital dye/radiotracer technique and have reported that these methodologies
complement one another and also have high rates of sentinel node iden-
tification (90%–100%) and accurate nodal staging (97%–100%) [43–45].
Recently, Ross et al [46] reported pooled results, from 22 centers, of
SLNBX being performed on 316 patients who had N0 head and neck
cancer. Although this study was not prospective, and the study population
was treated heterogeneously, these investigators reported a 95% rate of
sentinel node identification and an overall sensitivity of 90% for this
procedure. At centers that performed 10 or fewer procedures, the sensitivity
was 57%; centers that performed more than 10 procedures had a sensitivity
of 92% [46].
Although the data reported by Ross et al [46] are provocative, they must
be interpreted with caution because this study was performed in a patient
cohort that was nonrandomized, uncontrolled, retrospectively collected, and
heterogeneous. The results reported in the current literature are encourag-
ing, however. SLNBX does seem to be a technically feasible and accurate
method for staging N0 neck cancer. There remain many issues that must
be addressed before SLNBX becomes integrated into the management
algorithm of N0 neck cancer. Critical unresolved issues include the identi-
fication of patient/tumor characteristics appropriate for this methodology
(eg, stage, site, subsite) and a determination of the technique (eg, radio-
tracer, vital dye, or combination technique) most appropriately applied to
these individuals.
Summary
For individuals diagnosed with head and neck cancer, neck dissection
may be performed for therapy or disease staging. The classification of neck
dissection and the definition of precise anatomic landmarks have allowed
164 N.R. Rigual, S.M. Wiseman / Surg Oncol Clin N Am 13 (2004) 151–166
for this operation, and its many variations, to become standardized world-
wide. SLNBX shows promise in its ability to accurately stage N0 head and
neck cancer and may allow patients with no micrometastatic disease to
avoid neck dissection. Before this technique becomes adopted into routine
clinical practice, however, it must first be prospectively scrutinized in large
patient populations. Regardless of the future role of SLNBX in the man-
agement of head and neck cancer, currently it is only through a complete
understanding of the clinical, theoretic, and technical aspects of neck dis-
section that surgeons may benefit individual patients and the head and neck
cancer patient population as a whole.
Acknowledgment
The authors thank Paul Tomljanovich, MD, for his excellent artwork.
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Anatomy
A fundamental knowledge of the anatomy of the paranasal sinuses is
crucial in any discussion of malignancies of this region. The paranasal
sinuses consist of the paired maxillary, ethmoid, sphenoid, and frontal
sinuses (Figs. 1 and 2). Each sinus is named according to the bone that it
pneumatizes. The frontal sinus is located between the outer and inner tables
of the frontal bone. Each frontal sinus drains inferiorly by way of the
nasofrontal duct, which continues inferiorly to drain into the medial meatus
of the lateral nasal wall. The middle meatus is the area found inferior to the
middle turbinate and superior to the inferior turbinate. The dura of the
* Corresponding author.
E-mail address: larry.myers@utsouthwestern.edu (L.L. Myers).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00115-7
168 L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186
Fig. 1. Sagittal section of head, depicting position of paranasal sinuses and sectioning planes
1 and 2 of Fig. 2. AE, anterior ethmoid; ME, middle ethmoid ostium; OB, olfactory bulb; PE,
posterior ethmoid; SO, sphenoid ostium.
Fig. 2. Coronal section of head to illustrate relationships of paranasal sinuses (see Fig. 1 for
planes of sections 1 and 2).
are located anteriorly and laterally to the sinus. The maxillary sinuses and the
anterior ethmoid cells drain into the middle meatus [1,2]. The normally air-
filled sinuses surround the nasal cavity and are lined by ectodermally derived
respiratory epithelium, consisting of ciliated, pseudostratified, columnar
epithelial cells and interspersed mucus producing goblet cells. The lining of
the sinuses is continuous with the mucosa of the nasal cavity. The sinus
mucosa is thinner, however, and more adherent to the surrounding bone [1].
Incidence
Paranasal sinus cancers account for less than 1% of all malignancies and
comprise 3% of all head and neck malignancies [3]. The incidence rate is 0.3
to 1.0 case per 100,000 people per year in Western populations [4–6]. The
incidence is 2 to 3 times higher in Japan [7]. In the United States, the overall
male-to-female incidence is 3 to 2, with a strong predilection for whites. The
incidence rate of sinonasal cancer progressively increases after age 35.
Epithelium-derived neoplasms are almost nonexistent in children [5,6].
Etiology
The precise cause of paranasal sinus malignancies is unknown. Known
risk factors for the development of cancer in this region, however, include
170 L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186
wood and leather dust, smoke, and heavy metals, including nickel. Most
patients have a history of exposure to carcinogens for more than 10 years [8].
Pathology
The paranasal sinuses contain diverse components: schneiderian mucosa,
minor salivary glands, neural tissue, lymphatics, vessels, and bone. A
neoplasm may arise from any type of tissue present in the paranasal sinuses.
This article discusses epithelium-derived malignant neoplasms, including
lymphomas.
Epithelium-derived malignancies
Squamous cell carcinoma
Non–squamous cell carcinoma
Adenocarcinoma
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Melanoma
Olfactory neuroblastoma
Sinonasal undifferentiated carcinoma
Presenting symptoms/history
Patients typically present after symptoms have been present for several
months and the tumor has involved adjacent structures. Small tumors are
often asymptomatic but may present with nasal obstruction, epistaxis, or
symptoms consistent with chronic sinusitis, such as headache or rhinorrhea.
With involvement of surrounding structures, patients may experience
diplopia or vision changes, infraorbital nerve deficits, maxillary dental
symptoms, or possibly neurologic deficits secondary to intracranial
extension.
Evaluation
A suspected paranasal sinus malignancy requires a thorough head and
neck examination complemented by imaging studies. Office nasal endoscopy
under topical anesthesia allows assessment of the extent of a mass and its
fixation to surrounding structures. A biopsy can usually be performed in the
office setting. If there is concern for bleeding or the lesion is not easily
accessible, then endoscopic or open biopsy is best performed in the
operating room. A complete cranial nerve examination may disclose skull
base or direct nerve involvement by the tumor. A formal ophthalmologic
evaluation is recommended if there is concern for orbital involvement.
L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186 171
Staging
Staging paranasal sinus malignancies as a whole is imprecise and
controversial. A formal staging system has been developed only for maxillary
sinus carcinomas. In 1933, Ohngren [9] differentiated maxillary sinus tumors
based on whether they primarily involved the suprastructure or the
infrastructure of the maxillary sinus. Ohngren’s line runs from the medial
canthus inferiorly and laterally to the angle of the mandible. The
infrastructure of the maxillary sinus lies anterior and inferior to the line and
the suprastructure lies posterior and superior. Tumors of the infrastructure
are associated with a better prognosis because of decreased involvement of the
orbit and cranial base. In 1997, the American Joint Committee on Cancer
revised its 1977 criteria to more accurately correlate tumor stage and survival
[10]. The 1997 staging system is described in the following sections [11].
Tumor classification
T1: Tumors limited to antral mucosa, without bone erosion or destruction
T2: Tumor causing bone erosion or destruction, except for the posterior
wall, including extension into the hard palate or middle nasal meatus
T3: Tumors invading any of the following: posterior wall, subcutaneous
tissue, skin of the cheek, floor, or medial wall of the orbit,
infratemporal fossa, pterygoid plate, or ethmoid sinuses
T4: Tumors invading orbital contents beyond the floor or medial wall,
including any of the following: orbital apex, cribiform plate, base of
skull, nasopharynx, and sphenoid and frontal sinuses
172 L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186
Fig. 3. Axial contrast-enhanced MRI depicting actual extent of left posterior ethmoid sinus
adenocarcinoma. Black arrow indicates actual tumor. White arrow indicates inspissated mucus.
Node classification
N0: No regional node metastasis
N1: Metastasis to single ipsilateral node, less than 3 cm in greatest
dimension
N2a: Metastasis to single ipsilateral node, more than 3 cm and less than 6
cm in greatest dimension, or in multiple ipsilateral lymph nodes,
none more than 6 cm in greatest dimension
N2b: Metastasis to multiple ipsilateral nodes, all less than 6 cm in greatest
dimension
N2c: Metastasis to bilateral or contralateral nodes, all less than 6 cm in
greatest dimension
N3: Metastasis of more than 6 cm
Metastasis classification
M0: No distant metastasis
M1: Distant metastasis present
L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186 173
Disease stage
Stage I: T1N0
Stage II: T2N0
Stage III: T3N0 or T1-3N1 in greatest dimension
Stage IV: T4N0 or T1-4N2-3
Adenocarcinoma
Paranasal sinus adenocarcinomas differ from SCC in risk factors and
typical location. Chronic exposure to wood or leather dust has been cited as
a risk factor for the development of sinonasal adenocarcinoma in numerous
studies. Woodworkers in England have greater than a 1000-fold increased
incidence of ethmoid adenocarcinoma [17–24]. Adenocarcinomas account
for 17% to 90% of ethmoid malignancies, depending on geographic location
and occupational risk factors [25–27].
Sinus adenocarcinomas may develop from either minor salivary gland
tissue or the epithelium. Histologically, adenocarcinomas are classified as
low grade, high grade, or intestinal type. Low-grade adenocarcinomas
contain numerous glands lined by a single layer of cuboidal to columnar cells
with uniform nuclei. Papillary formations or large, irregular cystic spaces
may be present. High-grade lesions may demonstrate glandular structures
but are characterized by a solid growth pattern containing pleomorphism
and increased mitotic activity. Intestinal- or colonic-type adenocarcinoma
resembles intestinal adenocarcinoma and may contain goblet or signet ring
cells. All intestinal types are considered to be high-grade lesions [1].
Ethmoid adenocarcinoma typically requires a craniofacial approach for
resection. Postoperative radiation therapy is recommended for positive
margins, dural or cribiform plate invasion, and high-grade lesions adjacent
to the cribiform plate [28]. Wax et al [27] reported on eight patients with
adenocarcinoma of the ethmoid sinuses who were treated with craniofacial
resection, with follow-up periods ranging from 9 months to 5 years. Four
patients received postoperative radiation therapy. Seven patients have no
evidence of disease, including five patients who were observed for more than
3 years. Only one patient had positive margins secondary to brain
involvement and died of local recurrence at 8 months. The 5-year survival
rates after craniofacial resection ranged from 39% to 57% [29–31]. Knegt
et al [32] reported a 5-year survival rate of 87% in 70 patients treated with
surgical debulking and topical chemotherapy with 5-FU. The patients
received biweekly packing changes, removal of necrotic tissue, and topical
chemotherapy for 4 weeks. Selection bias likely contributed to the high
survival rate, however, because advanced tumors with invasion of dura or
the orbit were excluded from the protocol.
L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186 175
Melanoma
Sinonasal melanomas are rare neoplasms characterized by a poorer
prognosis than cutaneous melanomas. Malignant melanoma occurs in the
176 L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186
Lymphoma
Lymphomas of the paranasal sinuses are rare but are the most common
non–epithelial-derived neoplasm of the sinuses. Lymphomas of the
sinonasal tract account for less than 0.2% to 2% of extranodal lymphomas
in Western populations [59,60]. There is significant geographic diversity in
the incidence and histology of paranasal sinus lymphomas. In Asian
populations and in Peru, most cases are T-cell derived neoplasms affecting
young men. Most Western cases, however, are large B-cell–type lymphomas
diagnosed in elderly men [59–66]. The maxillary sinus is the most common
site of involvement. Orbital extension is more often associated with diffuse,
large B-cell lymphomas, whereas T-cell lymphomas more commonly involve
the nasal cavity [62].
If lymphoma is suspected, it is necessary to send biopsy specimens in
formalin and in saline to allow permanent section analysis and flow
cytometry. A combined modality approach with chemotherapy and
radiation therapy is the treatment of choice. A review of 70 patients who
had sinonasal lymphoma and who were treated at M.D. Anderson Cancer
Center reported improved prognosis with combined therapy versus
radiotherapy alone, yielding a 67% overall survival rate [61]. Cuadra-
Garcia et al [62] reported a significantly improved prognosis with patients
who had T-cell/natural killer cell lymphomas treated at Massachusetts
General Hospital compared with Eastern reviews. Approximately 11 of 15
patients were alive at a median follow-up period of 10 years, compared with
a median survival time of 6 to 25 months in Asian populations [67–69].
Because T-cell–derived lymphomas are associated with Epstein-Barr virus,
diversity of Epstein-Barr strains in the different populations may contribute
to the marked difference in disease course [62].
Treatment
Surgical treatment
A multidisciplinary approach is often used before resection of a paranasal
sinus cancer. Patients are presented to a tumor board consisting of
specialists in head and neck oncologic surgery, medical oncology, and
radiation therapy. Imaging studies are reviewed by a neuroradiologist. A
neurosurgeon is consulted if there is skull base involvement and
a craniofacial resection is anticipated. Formal ophthalmologic evaluation
is helpful when there is concern for orbital involvement. If a patient is
expected to require radiation therapy, the patient is referred to an oral
surgeon so that any needed dental extractions may be performed at the time
of surgery.
The goal of surgical resection is to remove the cancer en bloc, with
margins clear of neoplastic cells. For maxillary sinus neoplasms, maxillec-
L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186 179
[79]. Recent articles report similar local control rates with orbital
preservation in selected cases of infiltration of the periorbita. At the
University of Virginia, the invaded periorbita is resected, and the defect is
closed primarily or with temporalis fascia, without reconstruction of the
bony orbital wall [80].
Radiation therapy
Radiation therapy is often used with combination therapy, including
surgical resection. Multiple studies have demonstrated improved survival
with paranasal sinus malignancies with combined therapy compared with
single-modality treatment. Patients who have advanced lesions, positive
margins of resection, or regional metastasis should be evaluated for
radiation therapy. Before referral for radiation therapy, patients are
evaluated by an oral surgeon for extractions of diseased dentition to
decrease the risk of osteoradionecrosis. Patients are counseled regarding
potential adverse effects, such as xerostomia, hypothyroidism, middle ear
effusions, and blindness. Radiation therapy is typically started approxi-
mately 4 weeks after surgical resection.
Chemotherapy
In general, chemotherapy is of limited use for most sinus malignancies.
Chemotherapy regimens may be used with radiation therapy for palliation
of unresectable neoplasms. Chemotherapy is the primary treatment for
paranasal sinus lymphomas, however. Recent studies for aggressive cancers,
such as SNUC, have included chemotherapy, in addition to surgery and
radiation therapy. Thus far, however, no improvement in overall survival
rates has been demonstrated with such regimens compared with surgery and
radiation therapy.
et al [84] reported a regional recurrence rate of 38% with SCC and SNUC at
the M.D. Anderson Cancer Center. Several centers have reported improved
regional control with elective neck irradiation. Patients presenting with T3
or T4 maxillary sinus carcinomas routinely receive cervical radiation
therapy [81], whereas physicians at Loyal University of Chicago Medical
Center use radiation therapy with all maxillary sinus carcinomas [82].
Jeremic et al [85] achieved a 10-year regional control rate of 97% with
elective radiation and surgical salvage in 44 patients.
Prognosis/outcome
The overall survival prognosis for paranasal sinus malignancies remains
poor. Five-year survival rates range from 35% to 40% [12,86,87]. In Myers
et al’s [14] series of 141 patients with paranasal sinus malignancies, an ad-
vanced stage, nodal metastasis, and distant metastasis negatively influenced
survival. Survival rates are higher for maxillary sinus neoplasms compared
with other paranasal sinuses because of decreased incidence of skull base in-
volvement. There is a wide variety in the clinical courses of paranasal sinus
malignancies depending on the histopathologic type. Melanoma and SNUCs
are both aggressive neoplasms associated with a dismal prognosis, charac-
terized by local recurrence and metastatic spread. In contrast, patients who
have ACC often seem to have no evidence of disease during the first 5 years
after treatment. With a long-term follow-up period of 20 years, the most of
these patients develop a local recurrence or a metastasis.
Summary
Paranasal sinus malignancies are challenging to treat. Most patients
present with advanced lesions, often with intracranial or intraorbital
extension, and have a poor overall prognosis. Given the low incidence
and diverse pathologies of paranasal sinus cancers, it is extremely difficult to
perform prospective, randomized clinical trials to compare different
treatment approaches. Improving the prognosis of these cancers continues
to be a difficult task, even in light of advances in surgical techniques,
radiation delivery techniques, and new chemotherapeutic agents. Cranio-
facial resection techniques developed in the past few decades have cured
many patients with skull base invasion, who would have been considered
unresectable in the past. Furthermore, improvements in radiation therapy
can allow more accurate administration to the desired region, with
decreased damage to surrounding structures such as the orbit and brain.
Aggressive and oncologically sound surgical resection combined with
radiation therapy remains the treatment of choice for most patients.
Finally, advances in the diagnosis and staging by use of molecular or DNA
markers of tumor behavior may allow for more directed therapy.
L.L. Myers, L.E. Oxford / Surg Oncol Clin N Am 13 (2004) 167–186 183
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* Corresponding author.
E-mail address: james.schwarz@roswellpark.org (J.K. Schwarz).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00120-0
188 J.K. Schwarz, W. Giese / Surg Oncol Clin N Am 13 (2004) 187–199
briefly addresses the issue of quality of life in patients who have head and
neck cancer before discussing specific functions.
Finally, an article of this type should be able to make recommendations
as to what treatment regimens would be most appropriate for a given
situation. For organ preservation for head and neck cancer, this is a difficult
task. Some reasons for this difficulty include the following: the number of
randomized trials (particularly trials of surgery versus a nonsurgical modal-
ity) are limited, specific functional assessment (subjective and objective) is
not routinely performed in treatment trials, different assessment tools have
been used in different studies, patients have been assessed at different inter-
vals in different studies, and new technical changes in modalities of treat-
ment (ie, new surgical techniques, new radiation techniques) have not been
compared with each other.
Speech
In the early 1980s, the most aggressive treatment option (in terms of
survival) for patients with advanced larynx cancers was total laryngectomy,
possibly followed by adjuvant radiation therapy. Several phase 2 trials
demonstrated that some patients with advanced larynx and hypopharynx
cancer who responded to induction chemotherapy could be subsequently
treated successfully with radiation therapy and avoid a total laryngectomy
[5–7]. These studies provided the rationale for three trials in which patients
were randomized between initial surgery or induction chemotherapy fol-
lowed by radiation for those patients who responded to chemotherapy.
The Veterans’ Administration (VA) trial was initiated in 1985 and
randomized 332 patients with larynx cancer to primary laryngectomy or
a nonsurgical approach [8]. The nonsurgical approach started with two
cycles of cisplatin and 5-fluorouracil (5-FU) chemotherapy. Patients who
did not have a 50% or greater decrease in the primary lesion after two
cycles of chemotherapy underwent surgery. Patients with a 50% or greater
response (and no progression in neck disease) received a third cycle of
chemotherapy followed by definitive radiation. Approximately 64% of the
190 J.K. Schwarz, W. Giese / Surg Oncol Clin N Am 13 (2004) 187–199
who have undergone a total laryngectomy. This assumption has not been
clearly documented, however. As noted previously, in long-term follow-up
from the VA trial, patient-reported speech quality of life was similar in
patients with and without an intact larynx [13].
Whether radiation therapy can have adverse effects on larynx function is
not clearly known. Poor vocal function after radiation for larynx cancer
could be caused by the treatment or by irreversible damage from the cancer.
In patients who have small- to moderate-sized larynx cancers, improvement
in self-assessed speech has been shown to occur at 6 months after treatment
with radiation [16].
As mentioned previously, newer surgical techniques involving less than
a total laryngectomy may allow for reasonable voice production [14]. This
type of surgery can also obviate a permanent tracheostomy. Because a
tracheostomy contributes significantly to negative quality of life [17], sur-
gical options that avoid this procedure will result in improved quality of life,
regardless of vocal function.
Options for speech rehabilitation in patients who have undergone a total
laryngectomy include an electrolarynx, esophageal voice, and esophageal
voice with augmentation by a tracheoesophageal prosthesis (TEP) [18].
Voice function in patients who have larnyx cancer treated with radiation
has been compared with voice function in patients who have had a total
laryngectomy and speech rehabilitation with a TEP [19,20]. The perception
of speech by trained and untrained listeners was higher in patients who had
received radiation, but the difference was not large. In addition, there were
clear differences in patients who had received radiation compared with
control subjects who did not have larynx cancer. Most of the poor voice
quality in the patients who received radiation is likely caused by irreversible
damage from the cancer rather than the radiation, but this is not known
with certainty [21]. Furthermore, although a TEP can result in good voice
quality, this approach has not been successful in some patients.
Patients who have advanced larynx cancer, in whom a total laryngectomy
traditionally would be considered, often have significant impairment of
voice before treatment. Oncologically successful treatment of this popula-
tion with radiation should not be expected to restore excellent vocal
function in most of these patients. Surgical procedures that preserve some
form of laryngeal voice and avoid a permanent tracheostomy have the
potential to be associated with quality of life that might equal that asso-
ciated with nonsurgical treatments.
Swallowing
There are at least two basic considerations when evaluating swallowing
function in patients who have head and neck cancer: (1) the ability to
swallow itself and (2) whether there is aspiration.
J.K. Schwarz, W. Giese / Surg Oncol Clin N Am 13 (2004) 187–199 193
Patients who have head and neck cancer often have abnormal swallowing
before treatment. In one study using videofluoroscopy, 11 of 27 patients
with advanced head and neck cancers were found to have aspiration [22].
Impairment of swallowing was more closely associated with hypopharynx
and larynx cancers in another study [23], whereas in a third series, patients
with larynx cancers did not have the worst swallowing function [24]. Thus,
patients who have advanced head and neck cancers often have abnor-
mal swallowing function before treatment, and a nonsurgical treatment ap-
proach may not result in restoration of function, even if the treatment is
effective.
Swallowing after surgery for patients with head and neck cancers
Much of the literature concerning swallowing function after surgery has
focused on patients who have base of tongue cancer. Harrison et al [25]
reported that, in patients with base of tongue cancer, swallowing function
was better in those patients treated with radiation rather than surgery. A
later series from the same institution noted that patients treated surgically
may have swallowing function that is more comparable to patients treated
with radiation [26]. The extent of surgical resection for the base of the
tongue is hard to quantify, however, and the experience and opinion of the
consulting surgeon is invaluable in estimating the degree of swallowing func-
tion to be expected after surgery.
Surgery for head and neck cancer in sites other than the tongue of head
and neck cancer surgery can result in difficulty swallowing, but modern
methods of reconstruction have had reasonable functional outcomes [27–30].
Radiation can have detrimental effects on swallowing function (discussed
later), and patients treated with postoperative radiation have had swal-
lowing function that is inferior to patients treated by either surgery or radia-
tion alone [31].
Salivary function
Radioprotective agents
The concept that certain agents taken systemically might render a pro-
tective effect against ionizing radiation is not new [43]. WR-2721 (com-
monly known as amifostine; trade name, Ethyol) was developed circa World
War II by the US Army at the Walter Reed facilities with the hope it might
prove protective to troops in the field when and if they became exposed to
atomic fallout. The prodrug form becomes dephosphorylated to form an
activated free thiol, WR-1065 [44]. This free-radical scavenger is concen-
trated preferentially by normal rather than tumor cells [45]. The precise
reasons for this behavior is unclear, but may be because of the lower con-
centration of alkaline phosphatase in tumor tissue [46].
Data from randomized trials have concluded that amifostine reduces
both acute and chronic xerostomia in patients who have head and neck
cancer, with no evident tumor protection [47]. The drug has received Food
and Drug Administration approval to be marketed for that purpose, but is
limited to intravenous administration at 200 mg/m2 daily, given just before
irradiation. The drug may be useful for radiation-induced mucositis as well.
Practically, the drug seems to be tolerable for some patients, although
hypotension, nausea, and rash (both in and outside the irradiated portals)
limit its use in others. Pretreatment hydration and antiemetic agents seem to
be helpful.
Another agent with a differing mode of action touted as potentially useful
in the prevention or treatment of radiation-induced xerostomia is pilocarpine
hydrochloride. This parasympathomimetic agent stimulates secretion from
salivary glands. The theory is that stimulation of output from those acini
that remain functional translates into a reduction in the sensation of dry-
J.K. Schwarz, W. Giese / Surg Oncol Clin N Am 13 (2004) 187–199 195
Neuromuscular function
Neck function can be significantly altered by surgery and radiation.
Radiation can result in long-term decreased mobility of the neck tissues [51].
Surgical morbidity associated with neck dissection depends largely on the
extent of surgery; sparing of the spinal accessory nerve, sternocleidomastoid
muscle, and internal jugular vein are associated with improved function
[52–55].
In patients who have advanced head and neck cancers (ie, the patients for
whom the question of organ preservation is an issue), treatment decisions
concerning the neck often necessitate using both surgery and radiation.
Thus, the development of treatment strategies that result in improved
outcomes in neck function have lagged behind that of the primary sites.
For example, a clinically complete response to primary radiation alone in
patients with N2 or N3 disease in the neck would typically require a neck
dissection. It is not known if a neck dissection is required after a complete
response following concurrent chemotherapy and radiation for patients with
N2 or N3 nodal disease [56].
Summary
Treatment strategies that have the potential to improve functional organ
preservation in patients who have head and neck cancer are emerging. Clin-
ical research in this field, however, has been limited by the lack of stan-
dardized, objective criteria of organ function post treatment and by lack of
prospective assessment of organ function in treatment trials [56]. Advances
in surgical techniques, radiation techniques, radiation protectants, and
combined-modality therapies are promising, but well-planned and executed
clinical trials are necessary to determine how best to apply these techniques
to patient care.
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Surg Oncol Clin N Am 13 (2004) 201–229
Epidemiology
It is estimated that cutaneous melanoma of the skin comprised 5% and
4% of all new cancer cases in the United States among men and women,
respectively, in 2002 [1]. This statistic makes CMM the fifth and the sixth
most common cancer in the United States among men and women,
respectively [1]. In 2002, it was estimated that 53,600 new cases of CMM and
about 34,300 new cases of melanoma in situ were diagnosed. In the United
States, the lifetime risk for developing CMM is 1.72% (1 in 58) for men and
1.22% (1 in 82) for women. This lifetime risk increases with age (0.13%
at birth, up to 0.97% at 60–79 y for men; 0.19% at birth, up to 0.49% at
* Corresponding author.
E-mail address: jmyers@mdanderson.org (J.N. Myers).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00125-X
202 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Fig. 1. Incidence and mortality rates by gender. (From Ries LAG, Eisner MP, Kosary CL,
Hankey BF, Miller BA, Clegg LX, Edwards BK. The Surveillance, Epidemiology, and End
Results [SEER] Cancer Statistics Review 1973-1997; National Cancer Institute: Bethesda, MD,
2000. NIE pub. no. 00-2789; with permission.)
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 203
(1%) [5]. In addition, the survival rates differ depending on the specific
location of the melanoma in the head and neck, with the skin of the scalp
tumors with the worst rate, followed by those of the temple, ear, cheek, and
neck (Fig. 2) [6].
Mortality
The number of deaths attributed to melanoma was projected to be
approximately 7400 persons in the United States for 2002 [1]. This
represents a 2% annual surge in total mortality since 1960. The explanation
for this increase in mortality is a parallel increase in incidence. Despite of the
increase of melanoma, the 5-year survival rates for all ethnic groups in
the United States for CMM is on the rise: from 80% for 1974 to 1978, to
Fig. 2. Actuarial survival rates by site of primary tumor for patients with melanoma of the head
and neck. (From Ames FC, Sugarbaker EJ, Ballantyne AJ. Analysis of survival and disease
control in stage I melanoma of the head and neck. Am J Surg 1976;132:484–89; with
permission.)
204 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
85% for 1983 to 1995, to 89% for 1992 to 1997 [1]. These rates can be
attributed to an increase in earlier detection of the disease, allowing more
effective treatment in the earliest stages, rather than to a true improvement
in treatment.
Precursor lesions
Most patients who have head and neck melanoma have a history of a pre-
existing lesion. One report found that one third of melanomas arise from
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 205
congenital nevi, one third arise in nevi present for more than 5 years, and
one third arise in newly acquired nevi (nevi present for \5 y) [16].
Three types of lesions are known to be precursors to CMM. Congenital
nevi are usually present at birth. Patients with large congenital nevi (>20
cm) have a lifetime risk between 5% and 20% for developing CMM [17].
Dysplastic nevi may either occur sporadically or as a part of a familial
syndrome called dysplastic nevus syndrome (DNS). The lifetime risk for
CMM in the sporadic form is unknown, but the lifetime risk of CMM in the
DNS is believed to be close to 100% [18]. Lentigo maligna is considered to
be a preinvasive lesion of lentigo maligna melanoma and frequently occurs
on the head and neck region. The rate of progression of lentigo maligna to
melanoma is between 5% and 33% [18].
Patient characteristics
Certain phenotypic characteristics increase the risk for developing CMM.
These characteristics include blue or green eyes, blonde or red hair, a fair
complexion, a freckling pattern, and an inability to tan [19]. Rigel [20] used
multivariant analysis to identify six independent risk factors for CMM:
family history, freckling of upper back, blonde or red hair, history of 3 or
more years at an outdoor job as a teenager, history of 3 or more blistering
sunburns before the age of 20 years, and presence of actinic keratosis.
Individuals with one or two of these risk factors had a fivefold increased risk
of developing CMM, whereas those with three or more factors has
a twentyfold increased risk [20].
Genetics
Familial melanoma/dysplastic nevus syndrome
Members of familial melanoma and DNS families have a lifetime risk for
developing CMM approaching 100% [21]. Linkage analysis has shown the
involvement of several genes. An early, unconfirmed study that showed a
linkage of familial melanoma to chromosome 1p36 was followed by multiple
studies that demonstrated linkage to chromosome 9p21 [22–25]. Subsequent
investigations showed that the gene of interest at 9p21 was the previously
described p16 gene [26].
Xeroderma pigmentosum
Xeroderma pigmentosum (XP) is a hereditary syndrome that predisposes
individuals to the development of skin cancers. This rare autosomal-recessive
disease increases the risk of skin cancer in individuals with this syndrome by
1000 times more than that of the general public. Clinical features of XP
include early onset of freckling (by age 2 y) and multiple skin cancers,
including SCC, basal cell carcinoma, and melanoma. The onset of skin
cancers often occurs in individuals younger than 10 years who are affected
with this syndrome [27].
206 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Patients with XP are hypersensitive to the sun, and skin cells in these
patients exhibit decreased survival and increased mutagenesis after UV
radiation because of defects in nucleotide excision repair [28]. The
pathogenesis of skin cancers in XP patients highlights the important role
for UV-induced DNA damage in the development of all three types of skin
cancer.
Pathology
Lentigo maligna melanoma
Lentigo maligna melanoma is the least common subtype of melanoma,
comprising 5% to 10% of all cases. Its main characteristics include
a prolonged radial growth phase, which may last for decades. Therefore,
these tumors are fairly slow to invade. The neoplastic melanocytes remain at
the dermoepidermal junction, and the intraepithelial growth is along hair
follicles and sweat ducts. A differentiating feature of lentigo maligna
melanoma from lentigo maligna lies in the requirement of this melanoma to
invade into the papillary dermis.
Nodular melanoma
Nodular melanoma accounts for 10% to 15% of all melanoma cases. It is
characterized by a lack of radial growth and early vertical growth. It is
invasive almost from the onset.
Desmoplastic melanoma
This subtype of melanoma is characterized by a dermal population of
spindle cells among a fibrous stroma, a pattern that has been likened to
a ‘‘school of fish.’’ These lesions are often not pigmented. These lesions also
have been found to infiltrate and expand nerves and may show neural-like
differentiation. When this occurs, the term ‘‘neurotropic melanoma’’ is often
used. This affinity for perineural spread is crucial to consider during
evaluation and treatment [29].
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 207
Diagnostic evaluation
History
The key to effective treatment of malignant melanoma lies in early
recognition and diagnosis. Either the patient or a family member detects
approximately 75% of the cases, with the remaining 25% detected by
physicians [30]. The most common presenting signs are color change or
growth of a pre-existing lesion. In addition, other signs may include itching,
bleeding, ulceration, paresthesis, and pain. These signs usually are ominous,
late signs, which occur more often in thick melanomas rather than thin ones.
Physicians need to ask patients about overall sun exposure, family history of
melanoma, and about their history of sunburns.
Physical examination
A comprehensive assessment of the total number and types of moles
present is required. Physicians should look for congenital nevi, dysplastic
nevi, and lentigo malignas. On examination, a bright light and a magnifying
lens are needed to assess the size, color, border, and surface characteristics
(irregularly raised) of moles. Hallmarks of melanoma include the following:
(1) variation in color, (2) irregularly raised surface, (3) an irregular border,
and (4) ulceration. These features are what characterize benign from
malignant lesions.
ABCD checklist
The ABCD checklist is used by clinicians to identify potentially
malignant lesions [31]. The following clinical factors are included:
Assymetry. Assymetric growth patterns are caused by uneven growth
rates.
Border irregularities. Lesions that show border irregularities are likely to
be melanoma.
Color variegation. Differential coloring and shading indicates malignant
potential, especially red, white, and blue [32].
Diameter. Any increase in the size of a lesion, or a diameter greater than
6 mm, is suspicious.
All these factors have been found to predict malignant lesions to a varying
degree, with border irregularity being the strongest predictor [33].
Biopsy
All suspicious lesions should undergo biopsy to confirm the diagnosis of
melanoma and for accurate staging once the diagnosis is established. In
addition, the biopsy method of choice should not interfere with subsequent
208 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Staging
Anatomic location of the primary tumor
Numerous studies have shown the prognostic significance of anatomic
site of the primary tumor on survival rates. In an analysis of prognostic
factors in 8500 patients with CMM, Balch et al [36] showed that patients
with head and neck primary tumors are believed to have a worse prognosis
than patients with extremity tumors. Although controversial, several studies
have revealed that patients with tumors arising in the so-called ‘‘BANS’’
region (upper back, upper arm, posterior neck, and scalp) have lower
survival rates than those individuals with tumors arising in non-BANS
regions [37,38].
A review from the M.D. Anderson Cancer Center revealed that
melanoma lesions on the scalp do significantly worse than lesions on the
ear, face, and neck (see Fig. 2) [39]. This finding has been confirmed by other
studies [40,41].
Depth of invasion
During the 1960s, the landmark histologic staging of Clark [42], who
defined the levels of invasion, was set. The depth of invasion became the
most important prognostic factor for stage I and stage II melanoma tumors.
Breslow [43], however, demonstrated the importance of tumor thickness.
Currently, Breslow thickness represents a more powerful prognostic tool
than do Clark’s levels, although both remain widely used in the literature
and in clinical practice (Table 1).
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 209
Table 1
Histopathologic staging systems—Clark’s levels and Breslow thickness
Classification Characteristics
Clark’s levels
I Lesions involving only the epidermis (in situ melanoma); not an
invasive lesion
II Invasion of the papillary dermis but does not reach the papillary-
reticular dermal interface
III Invasion fills and expands the papillary dermis but does not penetrate
the reticular dermis
IV Invasion into the reticular dermis but not into the subcutaneous tissue
V Invasion through the reticular dermis into the subcutaneous tissue
Breslow thickness stage
I 0.75 mm
II 0.76–1.50 mm
III 1.51–4.0 mm
IV 4.0 mm
(stage III), and (3) distant disease (stage IV) [49]. Because of major advances
in the diagnosis and staging of CMM brought about primarily by the
development of SLN mapping and/or biopsy for the identification of
micrometastases, however, the new AJCC staging system incorporates
clinical and pathologic staging (Table 2).
The AJCC melanoma staging committee recommends that, when
possible, nodal staging should be performed and that, for clinical trials,
nodal staging is particularly important. Early-stage (I and II) localized
melanoma is a primary tumor without evidence of lymph node metastasis.
Ulceration of the primary tumor up-stages each T stage [50]. A new staging
category of IIC was designed for ulcerated T4 lesions. The IIC patients have
an equivalent prognosis as those with multiple metastatic lymph nodes [51].
The hallmark of stage III is the involvement of regional lymph nodes. The
presence of micrometastasis in the lymph nodes using SLN biopsy is
differentiated by the pathologic staging [52]. Patients with multiple lymph
node metastases and ulcerated primary tumors do worse are categorized as
having stage IIIC disease. Similarly, satellite or intransient metastases have
a poor prognosis and are up-staged to IIIB. Stage IV is defined by distant
metastasis and remains the same in the new system.
Table 2
New stage groupings for cutaneous melanoma
Clinical staginga Pathologic stagingb
Stage T N M T N M
0 Tis N0 M0 Tis N0 M0
1A T1a N0 M0 T1a N0 M0
1B T1b N0 M0 T1b N0 M0
T2a N0 M0 T2a N0 M0
IIA T2b N0 M0 T2b N0 M0
T3a N0 M0 T3a N0 M0
IIB T3b N0 M0 T3b N0 M0
T4a N0 M0 T4a N0 M0
IIC T4b N0 M0 T4b N0 M0
IIIc Any T N1 M0 — — —
— N2 — — — —
— N3 — — — —
IIIA — — — T1–4a N1a M0
— — — T1–4a N2a M0
IIIB — — — T1–4b N1a M0
— — — T1–4b N2a M0
— — — T1–4a N1b M0
— — — T1–4a N2b M0
— — — T1–4a/b N2c M0
IIIC — — — T1–4b N1b M0
— — — T1–4b N2b M0
— — — Any T N3 M0
IV Any T Any N Any M1 Any T Any N Any M1
a
Clinical staging includes microstaging of the primary melanoma and clinical/radiologic
evaluation for metastases. By convection, it should be used after complete excision of the
primary melanoma with clinical assessment for regional and distant metastases.
b
Pathologic staging includes microstaging of the primary melanoma and pathologic
information about the regional lymph nodes after partial or complete lymphadenopathy, except
for pathologic stage 0 or stage 1A patients, who do not need pathologic evaluation of their
lymph nodes.
c
There are no stage III subgroups for clinical staging.
Data from Balch CM, Buzaid AC, Atkins MB, Cascinelli N, Coit DG, Fleming ID,
Houghton A, Jr, et al. A new American Joint Committee on Cancer staging system for
cutaneous melanoma. Cancer 2000;88(6):1484–91.
Table 3
Recommendations for workup based on stage
Stage Workup
Melanoma in situ None
Stage I or II CXR, LDH
Stage I or II with ulceration or T3 CXR, LDH; consider lymphoscintigraphy
T4 or recurrent primary melanoma CXR, LDH
Consider metastatic imaging (CT of chest, abdomen,
pelvis, MRI of brain)
Stage III CXR, LDH (CT or US of the neck for regional
lymphatics); consider metastatic imaging for patients
with signs and symptoms of metastatic disease
Stage IV CXR, LDH, metastatic imaging (CT or US of
the head and neck, CT of abdomen, pelvis, chest,
MRI of brain)
Abbreviations: CXR, chest X ray; US, ultrasound.
Data from the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original
and primary source for this information is the AJCC Cancer Staging Manual, 6th edition (2002)
published by Springer-Verlag New York (For more information, visit www.cancerstaging.net).
Any citation or quotation of this material must be credited to the AJCC as its primary source.
The inclusion of this information herein does not authorize any reuse or further distribution
without the expressed written permission of Springer Verlag New York, Inc., on behalf of the
AJCC.
Management
General treatment options
Surgery
Surgery is well accepted as the primary treatment modality for CMM.
Complete surgical excision is recommended in most patients who have local
or regional disease in the absence of systemic disease. Recent studies have
indicated that a 2-cm margin around the primary tumor for intermediate-
thickness melanoma is sufficient [57]. For thinner lesions, 1-cm margins
provide equivalent local control and survival [58]. A crucial reminder is that
these recommendations are derived from studies of truncal and extremity
melanoma and that, in the head and neck, the surgeon may not have the
luxury of being able to take 1- to 2-cm margins without running the risk of
significant functional disability or cosmetic deformity.
A sound knowledge of the anatomy of the pathways of lymphatic spread
for CMM of the head and neck is essential. It is generally accepted that
clinically positive neck disease requires surgical treatment. In these patients,
it is important to address all the intervening lymphatics between the primary
tumor and the positive node or nodes. The type of neck dissection must be
tailored to the disease.
The treatment for clinically N0 neck disease is less definite. Patients with
stage I disease have a low rate of occult metastasis and thus may not need
surgical treatment of the neck. In contrast, a substantial number of patients
214 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Fig. 3. Predicted patterns of lymphatic drainage from primary sites in the head and neck.
Location of nodes: A, submental; B, submandibular; C, preauricular; D, jugular chain; E,
occipital; F, posterior cervical; G, retroauricular; H, jugulodigastric; and I, supraclavicular.
(From Byers RM. Cervical and parotid node dissection. In: Balch CM, Houghton AN, Milton
GW, et al, editors. Cutaneous melanoma. 2nd edition. Philadelphia: JB Lippincott; 1992. p. 377;
with permission.)
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 215
Fig. 4. Disease-free survival and disease-specific survival according to sentinel lymph node
status. Kaplan-Meier survival for patients undergoing sentinel lymph node biopsy. (A) Disease-
free survival. (B) Disease-specific survival. (From Gershenwald JD, Thompson W, Mansfield
PF, et al. Multi-institutional melanoma lymphatic mapping experience: the prognostic value of
sentinel lymph node status in 612 stage I or II melanoma patients. J Clin Oncol 1999;17:976–83;
with permission.)
216 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Radiotherapy
In the past, melanoma was believed to be a radioresistant tumor. The
past 20 years, however, have shown that different dosimetric and
fractionation schemes are needed for CMM treatment than those used to
treat other tumors. For example, significant improvements in locoregional
control have been noted with the use of adjuvant radiotherapy [68].
At M.D. Anderson Cancer Center, data reveal the possibility of attaining
a locoregional control rate of 88% in patients with stages II and III disease
when postoperative radiotherapy is used at a dose of 30 Gy given in 5
fractions [69]. In this trial, three groups of patients were investigated: (1)
those who underwent excision of stage III primary tumors, (2) those with
palpable lymphadenopathy who underwent WLE and neck dissection, and
(3) those with nodal relapse who underwent neck dissection. The locore-
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 217
gional control rates in all three groups were higher than in historical control
subjects. Moreover, the overall survival rate in patients with stage II disease
was higher than in historical control subjects (Fig. 5) [69].
In a more recent study, a retrospective analysis of 338 patients with lymph
node involvement who underwent complete lymph node dissection (LND) of
the nodal basin, which had pathologically involved lymph nodes, was
performed. The study showed that patients who have malignant melanoma
with nodal involvement have significant risk of nodal basin failure after LND
if they have cervical involvement, extracapsular extension, more than three
positive lymph nodes, clinically involved nodes, or any node that is larger
than 3 cm. Overall and disease-specific survival rates for all patients at 10
years was 30% and 36%, respectively. The rate of cervical nodal basin
recurrence at 10 years was 43%. This study concluded that patients with such
risk factors should be considered for adjuvant radiotherapy to the lymph
node basins to reduce the incidence of recurrence [70].
The M.D. Anderson Cancer Center recommends postoperative radio-
therapy for all patients with stage II lesions in which regional lymph nodes
are not treated surgically and in patients with pathologically proven nodal
disease or nodal recurrence, after nodal dissection has been performed.
Clinicians should bear in mind, however, that dosimetry is harmful to
nervous tissues and cannot be used for lesions near the eyes or central
nervous system.
Chemotherapy
Traditionally, chemotherapy served two main purposes: (1) as a palliative
therapy for patients with stage IV disease and (2) as an adjuvant therapy in
high-risk patients. The use of chemotherapy as an adjuvant therapy for
CMM still needs to be substantiated by prospective randomized trials.
Three major randomized trials have been performed using adjuvant
chemotherapy postoperatively [71–73]. In two of these studies, there was
no difference in disease-free interval or overall survival rates with
chemotherapy [71,72], and in the third study, worse overall survival rates
were found with chemotherapy [73]. Currently, the single most effective
chemotherapeutic agent approved for the treatment of advanced melanoma
is decarbazine. Response rates to decarbazine alone are 10% to 20%,
however. Using combination chemotherapy leads to a small, insignificant
improvement in response rates.
Immunotherapy
Because melanoma is the most immunogenic type of solid tumor, it serves
as a primary model for immunotherapy, both in animal models and in the
clinic. The approaches used to boost the body’s immune system include the
following: (1) biologic response modifiers (interleukins and interferons),
(2) immunostimulants, and (3) vaccines. All three approaches, though
promising, remain investigational. As in chemotherapy, the use of
218
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Fig. 5. Locoregional control and survival rates of patients treated with elective or adjuvant radiotherapy. (A) All patients. (B) Group 1, treated with elective
irradiation. (C) Group 2, treated with adjuvant irradiation after WLE plus neck dissection. (D) Group 3, treated with irradiation after nodal recurrence. (From
Ang KK, Peters LH, Weber RS, et al. Postoperative radiotherapy for cutaneous melanoma of the head and neck region. Int J Radiat Oncol Biol Phys
1994;30:296–8; with permission.)
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 219
Biochemotherapy
Biochemotherapy is the combination of two modalities of treatment:
immunotherapy and chemotherapy. This form of therapy attempts to
achieve responses higher than those achieved when either treatment is used
alone. At the M.D. Anderson Cancer Center, trials have usually combined
cisplatin, vinblastine, and decarbazine with interleuken 2 and IFN-a2b
[82]. The few prospective randomized trials showed similar survival rates,
higher response rates, and increased toxicity as compared with immuno-
therapy and chemotherapy alone [83–85]. Several large-scale trials
are currently underway to further evaluate the potential role of biochemo-
therapy, both as a postoperative adjuvant treatment and for treatment of
systemic disease.
220 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Treatment by stage
Three different aspects need to be addressed in the management of CMM
of the head and neck: the primary tumor, the regional lymphatics, and
distant metastasis. Although an acceptably high rate of locoregional control
has been established, many patients who have stage II disease and higher
eventually die of distant disease. The recommendations for treatment on the
basis of stage are presented in Table 4.
Melanoma in situ
For patients with melanoma in situ, the treatment of choice is surgical
excision with conservative margins (0.5–1cm) because the risk of metastasis
is essentially zero. No regional or metastatic workup is required.
Stage I
The recommended treatment in patients with stage I melanoma is WLE
[6]. Margins of 1 cm are generally acceptable. The defect can be closed
primarily or reconstructed using local flaps or skin grafts. Delayed
reconstruction is often advisable, given the limitations of frozen section
analysis of margins for pigmented lesions. As in melanoma in situ, no
regional or metastasis workup is needed because of the low risk of
metastasis in this group.
Table 4
Recommendations for treatment based on stage
Stage Treatment
I Primary tumor: WLE
II Primary tumor: WLE
Regional lymphatics: observation vs, END vs SLNB vs ENI
III Primary tumor: WLE
Regional lymphatics: neck dissection +/ÿ parotidectomy
Consider postoperative radiotherapy
IV Primary tumor: WLE
Regional lymphatics: neck dissection +/ÿ parotidectomy if node-positive
Metastasis site–directed surgery or radiotherapy
Consider systemic adjuvant therapy trials
Supportive care
Abbreviations: END, elective neck dissection; SLNB, sentinel lymph node biopsy; WLE,
wide local excision.
Data from the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original
and primary source for this information is the AJCC Cancer Staging Manual, 6th edition (2002)
published by Springer-Verlag New York (For more information, visit www.cancerstaging.net).
Any citation or quotation of this material must be credited to the AJCC as its primary source.
The inclusion of this information herein does not authorize any reuse or further distribution
without the expressed written permission of Springer Verlag New York, Inc., on behalf of the
AJCC.
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 221
Stage II
The adopted treatment in patients with stage II melanoma is WLE. If
possible, 2-cm margins are taken. If 1-cm or smaller margins are obtained,
adjuvant radiotherapy should be contemplated. As in stage I lesions, the
defect can be closed either primarily or reconstructed using local flaps or skin
grafts.
Given the substantial percentage of patients with stage II disease
harboring occult regional metastasis, elective neck treatment is often
considered. There are, however, no prospective trials to support the use of
any type of elective neck treatment for improving the locoregional control
and the overall survival rates. Once elective neck treatment is decided on,
there are several options to choose from.
END is the most widely adopted treatment option. The nodes of interest
are those considered to be at risk. A major advantage to END is the
prognostic information it provides. If occult metastasis is present, then
patients can be up-staged and are eligible for adjuvant systemic treatment
(immunotherapy, chemotherapy, or biochemotherapy).
Elective neck irradiation constitutes the second option. Locoregional
control rate is achieved in 85% of stage III patients who were given
irradiation to the primary site after WLE [68].
Finally, SLNB is still under investigation as a possible modality for the
evaluation of patients who have stage II melanoma.
Stage III
The recommendations for stage III disease include treating the primary
tumor by WLE and obtaining, if possible, a 2-cm margin. In addition, to
attain locoregional control, regional disease can be addressed by neck
dissection. If the disease allows, a selective or modified radical neck
dissection is advised rather than a classic radical neck dissection. In
addition, postoperative radiotherapy seems to increase locoregional control.
Unlike with stage I and stage II disease, systemic therapy, in the form of
chemotherapy, immunotherapy, or biochemotherapy, should be contem-
plated in patients with stage III disease because of the high risk for distant
metastasis.
Stage IV
Despite the dismal prognosis in this subgroup of patients, locoregional
control remains an important consideration because of the devastating
effects of uncontrolled locoregional disease. The overall treatment approach
in the treatment of stage IV metastatic melanoma is best determined by
a multidisciplinary team, including a surgeon, radiation oncologist, and
medical oncologist, and is often best performed in the context of
a prospective clinical trial. Palliative and supportive care is also an
important issue to address in these patients.
222 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Recurrent disease
Recurrent disease is usually associated with a poor prognosis. The
recurrence can be locoregional or distant. For locoregional recurrence, re-
excision [86], if possible, and adjuvant radiotherapy (if it has not been
administered before) are indicated. If surgery is not an option, radiotherapy
and systemic therapy are secondary options, but they can only be palliative
at this stage. Distant metastases that are surgically resectable should
be aggressively treated because, in rare instances, a cure or long-term
progression-free interval can be achieved. Sometimes, however, isolated
distant metastases are kept in place to initially ‘‘monitor’’ the response to
systemic treatment, and then depending on the result, excised later on. The
prognosis for pulmonary metastasis is better than brain and liver metastasis,
which carries with it a dismal expected survival time of 2 to 4 months [87].
Even in the context of recurrent disease, every effort should be made to
achieve locoregional control, if only to improve the patients’ quality of life.
Follow-up
Because CMM is a disease of young people (average age, 45 y), both the
clinical and financial aspects of the patient’s follow-up are important and
need to be addressed. Weiss et al [88] reported that intensive follow-up in the
post-treatment phase (5 y) costs around $421,000 for laboratory tests alone
[88]. Thus, the need arises to establish equilibrium between what can be
called an ‘‘adequate’’ surveillance and fiscal responsibility. An estimated
28% to 56% of recurrences are usually detected by physicians [89,90].
Therefore, physical examination when supplemented with periodic labora-
tory testing and radiologic assessment is a good basis for follow-up. At the
M.D. Anderson Cancer Center, the follow-up depends on the stage of the
disease at diagnosis (Table 5).
Table 5
Recommendations for follow-up based on stage
Stage Physical examination Radiology Labs
Melanoma in situ Every 6 mo4 y, then annually None None
Stage 1 or II (no ulceration, Every 6 mo4 y, then annually CXR LDH
thickness \1.0 mm)
Stage I or II (with ulceration Every 6 mo2 y, then every CXR LDH
or thickness >1.0 mm) 6 mo2 y, then annually
Stage III or recurrent primary Every 3 mo2 y, then every CXR LDH, CBC
melanoma 6 mo3 y, then annually
Stage IV Individualize Individualize Individualize
Abbreviations: CBC, complete blood count; CXR, chest X-ray.
Data from the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original
and primary source for this information is the AJCC Cancer Staging Manual, 6th edition (2002)
published by Springer-Verlag New York (For more information, visit www.cancerstaging.net).
Any citation or quotation of this material must be credited to the AJCC as its primary source.
The inclusion of this information herein does not authorize any reuse or further distribution
without the expressed written permission of Springer Verlag New York, Inc., on behalf of the
AJCC.
survival rates depend on the anatomic site of the primary lesion [91] and are
40% for oral lesions and 47% for sinonasal lesions [93]. In addition, most of
the staging criteria for CMM, including depth of invasion and regional
lymphadenopathy, fail to impact or affect the prognosis in mucosal
melanoma. The only significant and independent predictors of the
development of distant failure and death in patients who have mucosal
melanoma of the head and neck are as follows: the clinical stage at
presentation, whether the tumor thickness is greater than 5 mm, whether
there is vascular invasion on histologic studies, and the development of
distant failure [92,93].
As a group, mucosal melanomas of the head and neck are highly
aggressive and rapidly fatal [91]. Radical surgery with aggressive resection of
the primary tumor is the primary treatment used to achieve locoregional
control [93]. Adjuvant radiotherapy does improve locoregional control;
however, it probably does not affect overall survival rates because of the
high rates of distant metastasis at the time of initial presentation [94].
Overall 5-year survival rates are usually between 15% and 20%, although
rates as high as 40% have been reported [92,95].
Desmoplastic melanoma
Desmoplastic melanoma (DM) was first described by Conley et al [29], in
1971, as a rare variant of spindle cell melanoma. These lesions are often
nonpigmented and may appear only slightly abnormal or harmless when
actually an aggressive malignant lesion is present. The seemingly benign
appearance of this tumor can be misleading to patients and physicians alike,
causing a delay in proper therapy. Previous studies have noted that DM was
224 M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229
Summary
Major advances in the understanding of the causes and risk factors for
melanoma and for the prevention and management of this tumor have taken
place since the beginning of the past century, when the diagnosis of
melanoma was synonymous with death. As many as 80% of early
melanomas can be cured, and a high rate of locoregional control for even
far-advanced melanoma is plausible. The major challenge for the years to
come lies in curtailing the steady rise in the incidence of melanoma by
increasing patient education and adopting measures to prevent the
increasing mortality rates associated with this disease. Cure rates can be
improved by early diagnosis by physicians and instant referral to ex-
perienced oncologists. Finally, new advances in diagnostic and treatment
strategies carry the hope for further improvements in locoregional control
and survival rates.
M.N. Younes, J.N. Myers / Surg Oncol Clin N Am 13 (2004) 201–229 225
Acknowledgments
The authors thank Bradley A. Schiff, MD, for his review and critique and
Ms. Yolanda Luna for her administrative assistance.
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Surg Oncol Clin N Am 13 (2004) 231–239
* Corresponding author.
E-mail address: kgibbons@Buffns.com (K.J. Gibbons).
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00116-9
232 K.J. Gibbons, A.O. Dare / Surg Oncol Clin N Am 13 (2004) 231–239
lumbar drainage. The authors also reviewed the syndrome and its
management, the theory of cranial spinal pressure gradients, and the
practical details of successful lumbar drainage (eg, minimal duration;
volume drainage targets; and careful frequent nursing care, ideally in an
ICU setting).. An important practical point is the need to clamp the catheter
at the first sign of neurologic decompensation, as opposed to removing the
catheter, which could result in uncontrolled drainage into the soft tissues of
the back and further herniation.
Another study reported two patients with coma associated with
overdrainage from a lumbar catheter, with the recommendation to attempt
cranial catheter placement, either subarachnoid or intraventricular, to avoid
the pressure gradient across the foramen magnum when possible [4]. Uncal
or transtentorial herniation syndromes occur in the setting of temporal lobe
edema or hemorrhage and lumbar drainage, with potentially devastating
results. Ventriculostomy placement is not without risk, however. Risks
include intraparenchymal hemorrhage and, in particular, serious central
nervous system (CNS) infection, which is uncommon with lumbar drains. A
recent review of ventriculostomy-related infection and specific risk factors
was published by Lozier et al [5].
The decision to place a lumbar drain is usually made before surgery, in
cases where significant dural reconstruction is likely to be required. The
placement of a catheter into the subarachnoid space before craniotomy,
after induction of general anesthesia, is advantageous for the following
reasons:
1. The lumbar subarachnoid space is easily and safely entered before
drainage of large amounts of CSF at the primary surgical site (dry taps
are more likely to result in root injury or irritation).
2. Controlled drainage during surgery facilitates exposure and minimizes
brain retraction.
3. Large-bore (14- or 16-gauge) Tuohy needles are more comfortably
placed in patients under general anesthesia (from both the patient’s and
surgeon’s perspective).
4. Securing the catheter at multiple sites by suture fixation of the looped
catheter is often essential to maintain a working catheter for 5 days or
more; this procedure is easier to perform under general anesthesia.
5. The most tenuous cranial/dural base repairs can be disrupted by even
brief periods of intracranial hypertension associated with Valsalva’s
maneuvers and other events during emergence from anesthesia; CSF
drainage may avoid these periods of intracranial hypertension.
Imaging
Neurosurgeons relied on clinical acumen and knowledge of neurology
and anatomy to guide surgery for the first 70 years of the specialty, from the
days of Harvey Cushing until the advent of CT in the 1970s. Until CT
became available, neurodiagnostic testing included air ventriculograms,
pneumoencephalograms, and contrast angiography, with toxic agents
delivered by direct carotid puncture. With the introduction of CT and
subsequently MRI, the location and extent of lesions were no longer in
doubt. Neurosurgery as a specialty was reborn based on modern neuro-
imaging. Standard CT acquisition was slow, however, with thick (5–10 mm)
slices, significant volume averaging, and very limited nonaxial slice imaging
or reconstruction capability. MRI provided better views of nonosseous
K.J. Gibbons, A.O. Dare / Surg Oncol Clin N Am 13 (2004) 231–239 237
structures in three standard planes but required lengthy scan times and
a cooperative patient, and often included significant artifacts.
The introduction of improved hardware and software in both CT and
MRI modalities greatly aids modern-day skull base surgeons. Thin-slice
high-resolution CT with multiplanar reconstruction and workstation
capabilities allows the surgeon to rotate, magnify, and adjust windows
and plan approaches before incision. CT had been relegated to a distant
second place in terms of value to the surgeon; however, improved computer
capabilities has returned the modality to equal footing with MRI,
particularly in cranial base surgery.
CT and MRI have advanced the specialty of neurosurgery in general and
skull base surgery in particular. Those images initially were only pre-
operative, however, and although of great use to the surgeon, were only
images on a light box in the operating room, not always readily or
accurately transferable in the surgeon’s mind to the three-dimensional field
in which he or she must work. Now, imaging is available with three-
dimensional reconstruction, thin-slice multiplanar imaging, intraoperative
localization (frameless stereotaxy), and intraoperative MRI.
Framed stereotactic techniques in neurosurgery involve the application of
a head frame and localizer ring, image acquisition in the ring, and transfer to
the operating suite with frame attached. Image fusion permits accurate
localization and target identification, as described later. Operative
localization of a predetermined target is useful; however, framed stereotactic
surgery did not allow for reorienting the surgeon. In addition, operating
around a frame is difficult for extensive or lengthy procedures. The concept
of frameless stereotaxy involves preoperative imaging with fixed reference
points, either anatomic structures or fiducials, which are then referenced in
the operating room with a system that allows the surgeon to reorient the
location of a probe or any surgical instrument to a three-dimensional
display in the operating suite. The use of frameless systems for intra-
operative navigation is increasing in neurosurgery and otolaryngology, and
numerous systems are available [12,13]. These systems include those with
reference points with fixed arcs attached to typical neurosurgical head
frames; those with localized skull pins, dental stents, or reference blocks and
less invasive localizing points; and, in surgery, those with tool localization
based on ultrasound, optics, and articulated arms that allow the surgeon to
know where in three-dimensional space he or she is working.
Combining these modalities in overlaid sections and rendered three-
dimensional images is the result of image fusion. The use of fusion
techniques in preoperative frameless guidance combines the submillimetric
accuracy of CT with the tissue-imaging capabilities of MRI, and more
accurately displays the information than either modality alone [14]. This
fusion technique, with accurate three-dimensional renderings, provides
better depiction of individual anatomic structures and key structural
relationships (eg, tumor–bone and tumor–vessel) [15].
238 K.J. Gibbons, A.O. Dare / Surg Oncol Clin N Am 13 (2004) 231–239
Intraoperative MRI
The latest and potentially most useful imaging modality in the surgical
suite is real-time intraoperative image acquisition that demonstrates the
surgical anatomy and remaining pathology as the procedure evolves.
Intraoperative MRI is now available, with intraoperative magnets of 0.12-
to 1.5-T field strengths now available. MRI surgical suites and compatible
operating equipment, consisting of anesthetic and surgical instruments, are
now available [20]. The transition period from research tool to widespread
clinical applications is now upon us. The use of updated images eliminates
the concern of brain shift and should reduce the occurrence of unsuspected
tumor remnants and the need for return trips to the operating room. In the
future, the routine use of intraoperative MRI may provide intraoperative
quality assurance in neurosurgery and skull base surgical procedures.
Summary
The recent advances in neurosurgery, applied to the growing field of skull
base surgery, provide surgeons with new techniques to avoid the devastating
complication of CSF leak, to improve patient selection by reducing the risk
of stroke while expanding the operative options available to patients with
head and neck malignancies, and to aid operative care through improved
surgical planning and intraoperative localization.
References
[1] Shapiro S, Scully T. Closed continuous drainage of spinal fluid via a lumbar catheter for
treatment or prevention of cranial/spinal cerebrospinal fluid fistula. Neurosurgery 1992;20:
241–5.
K.J. Gibbons, A.O. Dare / Surg Oncol Clin N Am 13 (2004) 231–239 239
Index
Note: Page numbers of article titles are in boldface type.
D
C
Dental oncology, expanding role in head
Cancer predisposition, in patients with and neck surgery, 37–46
squamous cell carcinoma of head and assessment, 38–40
neck, 2–4 considerations during treatment,
genes for, 5–6 40–41
genomic instability and, 4–5 long-term considerations, 41–43
Carotid artery, assessment, preservation, Desmoplastic melanoma, 206, 223
sacrifice, and bypass of, in skull base
surgery for head and neck cancer, Differentiated thyroid carcinoma. See
235–236 Thyroid carcinoma.
1055-3207/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1055-3207(03)00146-7
242 Index / Surg Oncol Clin N Am 13 (2004) 241–247
Iodine 131, for adjuvant therapy of Mandible, squamous cell carcinoma of,
well-differentiated thyroid carcinoma, surgical treatment of, 58
129–149
Maxillofacial prosthodontics, dental
acute and long-term effects of
therapy, 137–140 oncology in head and neck cancer, 40
further management, L-thyroxine Melanoma, of head and neck, 201–229
therapy, 142–144 causes and risk factors,
serum Tg testing and 204–206
rhTSH, 145 diagnostic evaluation, 207–208
imaging and follow-up, epidemiology, 201–203
140–142 follow-up, 222
outcomes, 142 management, 213–222
postsurgical remnant ablation, biochemotherapy, 219
134–135 by stage, 219–221
therapy of metastases from, chemotherapy, 218
135–137 immunotherapy, 218–219
radiotherapy, 216–218
surgery, 213–216
L mortality, 203
L-Thyroxine, therapy with, after iodine 131 of paranasal sinuses, 175–176
therapy for differentiated thyroid pathology, 206
carcinoma, 142–144 recurrent disease, 221
Larynx, squamous cell carcinoma of, salivary gland, 121–122
99–112 special issues, 222–224
anatomy, 100–101 desmoplastic melanoma,
complications and outcomes, 223
108–109 metastatic melanoma of
diagnosis, 102–104 unknown origin,
lymphatic and distant spread, 223–224
101–102 mucosal melanoma,
pathology, 104 222–223
preserving speech in patients staging, 208–213
with, 189–192 Metastases, imaging of nodal disease in
radiotherapy and chemotherapy head and neck oncology, 16–22
in treatment of, 107–108 metastatic melanoma of unknown
selective neck dissection for, 157 origin, 223–224
staging and prognosis, 102 of paranasal sinus cancers, 181–182
surgical treatment, 104–107 to neck, of hypopharyngeal
Lentigo maligna melanoma, 206 carcinoma, 90
to neck, of oropharyngeal carcinoma,
Lip, squamous cell carcinoma of, surgical 77–78
treatment of, 57–58
Molecular biology, of salivary gland
Lymph nodes, cervical, anatomic landmarks cancers, 122–123
for identification of, 153–154
sentinel, biopsy of for staging N0 neck Mortality, due to melanoma of head and
tumors, 161–163 neck, 203–204
V X
Voice, preservation of. See Speech. Xeroderma pigmentosum, as risk factor for
cutaneous malignant melanoma,
205–206
W
Wound closure, integration of neurosurgical Xerostomia, preservation of salivary
techniques into skull base surgery for function in patients with head and
head and neck cancer, 233–235 neck cancer, 194–196