- Email: [email protected]
S18. Treatment of patients with advanced (N2–N3) metastatic lymph nodes
Abstracts / Oral Oncology 47 (2011) S15–S27
S15. Treatment approach for head and neck cancers with HIV infection Gerald Paris Head and Neck Clinic, Tygerberg Hospital, University of Stellenbosch, South Africa Introduction: Tygerberg hospital is one of two academic centers serving the Western Cape Province in South Africa. About 400 head and neck cancer patients pass through the center annually; the majority at an advanced stage. All have HIV screens done routinely before referral to our unit although we generally do not factor this in unless there is an unexpected development or unusual decision; in the majority of cases their general condition and the cancer stage is the major determining factor in the management decisions. Discussion: The approach to dealing with the pattern of diseases we face is complicated by an extremely high rate of TB, an erratic supply of anti-retrovirals and extreme pressure on our logistics. Despite all the above problems, a good and sensible palliation is achieved by treatment and reasonable holistic support. There remains an enormous potential for further development, both clinical and academic and we look forward to a multi-national activities to this end in the future.
S19
widely available as it should be and expertise in treatment techniques and use of advanced technologies needs to be developed. AFROG, whose membership comprises of Radiation Oncologists, Medical Physicists and Radiation Therapy Technicians from all over the African continent is one of the available platforms for educational activities and the development of partnerships to combat cancer in the African continent through the various oncology centres in the region. The organization recognizes the multidisciplinary approach to cancer management and so aims to broaden the its activities to include other disciplines. Through IAEA sponsored regional training courses, the treatment of head and neck cancers has been addressed to some extent but there is still an need for this group of cancers to be highlighted especially with the changing epidemiology of these cancers in the era of the human immunodeficiency virus (HIV) epidemic that has affected the greater part of Africa. Discussion: Africa had limited resources to manage cancers in general. Head and neck cancers are a significant burden to cancer these overburdened treatment facilities in the region. This necessitates special consideration of the management of these cancers which are now easily curable in other regions where early presentation is a feature but are still a major cause of cancer fatalities in Africa. Collaboration within the continent and externally would have a big a role to play in the control of these cancers.
doi:10.1016/j.oraloncology.2011.06.079 doi:10.1016/j.oraloncology.2011.06.080 S16. Role of AFROG in improving the management of head and neck cancers in Africa Ntokozo Ndlovu
Sponsored Symposium #6:
Department of Radiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
S17. Patient-related factors associated with poor outcomes André Lopes Carvalho
Introduction: The African continent has a wide variety of head and neck cancers according to the subregions. While in North Africa most of these cancers are as a result of smoking and are commonly the classical squamous cell carcinomas, in Central and Southern Africa the HIV epidemic has changed the cancer scenario and head and neck cancers have not bee spared. Manifestations of Kaposi’s sarcoma and non-Hodgkins lymphoma in the head and neck region is a common feature in the cancer treatment clinic. The region has a limited cancer treatment capacity in general due to limited human and economic resources. Methods: The African Radiation Oncology Group (AFROG) is an organization that aims to promote Radiation Oncology and other health practices relevant to the management of cancer within African countries through exchange of knowledge and technology between African countries, continued education, provision of technical expertise, supporting of prevention, early detection and treatment facilities, promotion of radiation safety and research. There is in particular, a recognition of the burden of head and neck cancers in the African region and the need for strategies to combat this group of cancers. The organization also aims at forming liaisons with other organizations of similar interest internationally to achieve its goals. Results: The major collaborator for AFROG is the International Atomic Energy Agency (IAEA) through its Technical Cooperation Department, the Division of Human Health and the Programme of Action for Cancer Therapy (PACT). Radiation therapy is an important part of the treatment of head and neck cancer. In Africa, patients needing this form of treatment could are likely to constitute a higher proportion that in other parts of the world, this being as a consequence of late presentation when surgery is no longer feasible. Unfortunately this treatment is not as
Department of Head and Neck Surgery, Barretos Cancer Hospital, Barretos, Brazil Brazilian Society of Head and Neck Surgery (BSHNS) Advanced oral cancer per se is related to a poor prognosis. However, the literature has shown that factors related to the patient can influence the outcome and stratify prognostic groups within these patients. The main factors related to the patient that can be associated with prognosis are age, race, education, socioeconomic status, comorbid conditions, performance status, symptom distress, among others. The relationship of those factors and prognosis can be due mainly on how they influence access to a proper treatment, the possibility of performing the standard treatment, besides how physicians are influenced in not delivering the standard treatment. We need to discuss how patient-related factors are associated with outcome in advanced oral cancer patients and mainly what are the possibilities for reverting this scenario in selected cases. doi:10.1016/j.oraloncology.2011.06.081
S18. Treatment of patients with advanced (N2–N3) metastatic lymph nodes Fernando Walder ENT and Head and Neck Surgery Department, The University Federal of São Paulo, Brazil Despite the use of aggressive single or multimodality treatment protocols, patients with advanced cervical metastases, N2 and N3,
S20
Abstracts / Oral Oncology 47 (2011) S15–S27
have a poor prognosis because of their high risk of regional and distal failure. Moreover, N3 class does not allow resectability and curability to be defined. Numerous trials have been carried out in order to improve the oncological outcomes of patients with advanced metastases to the neck using a variety of multimodality therapy. The presence of advanced cervical metastases is a very poor prognostic factor. The combined treatment modality offers better chances of cure than single modality treatment. Surgery followed by radiotherapy or chemo-radiation therapy is an effective and well-standardized approach. The use of planned neck dissection following chemoradiation is still debated. doi:10.1016/j.oraloncology.2011.06.082
S19. Long term cosmetic and functional results of reconstruction using myocutaneous and free flaps Rogério A. Dedivitis Department of Head and Neck Surgery, Hospital das Clínicas, São Paulo School of Medicine University of São Paulo, Brazil Department of Head and Neck Surgery, Fundação Lusíada and Metropolitan University, Santos, Brazil Radical surgery along with radiation therapy remains the treatment of choice for advanced oral cancer. Since surgery is required, a major emphasis is placed on providing successful reconstruction which is intended to maintain both function and appearance. However, it is a difficult and challenging task. Primary closure, skin grafts, fasciocutaneous flaps, myocutaneous flaps and free flaps have been described in order to repair these defects. This choice depends on the site, type and extension of the defect. Furthermore, it depends on the expertise of the surgical staff and its availability for more complex approach, which is particularly troublesome in developing countries. Deterioration of the quality of life and pulmonary, swallowing, speech and cosmetic impairment after treatment can be properly evaluated by means of reliable and valid questionnaires. This evaluation can influence the preoperative decision, as well.
itation of swallowing. A comparison between the oncologic and functional results prior to 1998 and thereafter is the subject of this report. Before 1998 owing to non availability of micro vascular free flap reconstruction options, such mega resections received regional flaps with resection of posterior segment of mandible to facilitate insetting of flap, despite mandibular invasion noted only in 1/4 th of resected specimens. Microscopic positive margins viz. R1 resections were seen in 21% of cases and a loco regional control rate at 2 years was 45%, with almost all the cases (N = 22) done as planned primary surgery followed by adjuvant post op radiotherapy. Swallowing rehabilitation was stormy and required intensive swallowing therapy lasting 2–3 months at the end of which two thirds of patients swallowed thickened liquids and liquids at best without troublesome aspiration. The rest were dependent on some form of enteral alimentation, namely feeding jejunostomy or gastrostomy. Since late 1990s the same operation was carried out in 20 cases of advanced tongue cancer; 14 cases (that did not require segmental resection of mandible) underwent primary surgery with mandibulotomy approach and free micro vascular flap for soft tissue reconstruction and laryngeal elevation. Microscopic positive margins (R1) were seen in 15% and all received post op adjuvant chemoradiotherapy. This group of 14 cases had loco regional control of 65% at 2 years; on the rehabilitative front the final resumption of oral nutrition without significant aspiration was achieved in 12/14 within a period of 4–6 weeks. In 2 of these cases owing to unsuccessful rehabilitation secondary to significant aspiration there was dependence on a G tube. In those that achieved oral alimentation, nature of food consistency at the end of rehabilitation remained the same as in the pre 1998 cohort. Careful patient selection, adoption of mandibulotomy approach with micro vascular free flap reconstruction with laryngeal elevation seem to lend themselves to better local control with satisfactory swallowing sans aspiration in majority. Swallowing therapy under the supervision of expert in such a scenario has made this operation well worth the effort, both oncologically and functionally. doi:10.1016/j.oraloncology.2011.06.084
doi:10.1016/j.oraloncology.2011.06.083 Sponsored Symposium #7 S20. Challenges in rehabilitation after sub-total and total glossectomy with laryngeal preservation Ashok M. Shenoy a, Anand Krishna, Poornima Shenoy, Premalatha, Rahul, Sharath Dept. of Head & Neck Surgery, Kidwai Memorial Institute of Oncology, Bangalore, India Total glossectomy and sub-total glossectomy defined as ‘‘resection with removal of greater than 70% of tongue ‘‘(oral and posterior tongue) with laryngeal preservation despite ipsilateral, hypoglossal and lingual nerve sacrifice is a formidable operation, which is still performed for oncological control owing to lack of comparable alternative treatment strategy for these advanced tumors. This study is a single center experience over 2 decades since 1990, of trends in surgical extirpation of massive lesions (T3 and T4a) that may have initially originated either in anterior two thirds of tongue or tongue base or both. After 1998 there have been several trends adopted largely to facilitate early post surgical rehabil-
a
Visiting Proferssor, Hospital Das Clinicas, Sao Paulo, Brazil, 1996.
S21. Complex issues in cancer of the oral cavity Ashok R. Shaha International Federation of Head and Neck Oncologic Societies (IFHNOS), New York, USA International Federation of Head and Neck Oncologic Societies (IFHNOS) In spite of serious efforts to diagnose cancer of the oral cavity and perform close surveillance, approximately two-thirds of patients still present with locally advanced cancer of the oral cavity. This leaves the physician with several complex issues in the management of cancer of the oral cavity, including locally advanced cancers, involvement of the mandible, management of advanced neck disease, and mandibular reconstruction. Complications, such as osteoradionecrosis which continues to be a major issue after initial radiation therapy or postoperative radiation therapy, will be discussed. A majority of advanced cancers of the oral cavity are best treated with surgery and postoperative radiation therapy. However, a small percentage of patients may receive non-operative therapy.
S15. Treatment approach for head and neck cancers with HIV infection Gerald Paris Head and Neck Clinic, Tygerberg Hospital, University of Stellenbosch, South Africa Introduction: Tygerberg hospital is one of two academic centers serving the Western Cape Province in South Africa. About 400 head and neck cancer patients pass through the center annually; the majority at an advanced stage. All have HIV screens done routinely before referral to our unit although we generally do not factor this in unless there is an unexpected development or unusual decision; in the majority of cases their general condition and the cancer stage is the major determining factor in the management decisions. Discussion: The approach to dealing with the pattern of diseases we face is complicated by an extremely high rate of TB, an erratic supply of anti-retrovirals and extreme pressure on our logistics. Despite all the above problems, a good and sensible palliation is achieved by treatment and reasonable holistic support. There remains an enormous potential for further development, both clinical and academic and we look forward to a multi-national activities to this end in the future.
S19
widely available as it should be and expertise in treatment techniques and use of advanced technologies needs to be developed. AFROG, whose membership comprises of Radiation Oncologists, Medical Physicists and Radiation Therapy Technicians from all over the African continent is one of the available platforms for educational activities and the development of partnerships to combat cancer in the African continent through the various oncology centres in the region. The organization recognizes the multidisciplinary approach to cancer management and so aims to broaden the its activities to include other disciplines. Through IAEA sponsored regional training courses, the treatment of head and neck cancers has been addressed to some extent but there is still an need for this group of cancers to be highlighted especially with the changing epidemiology of these cancers in the era of the human immunodeficiency virus (HIV) epidemic that has affected the greater part of Africa. Discussion: Africa had limited resources to manage cancers in general. Head and neck cancers are a significant burden to cancer these overburdened treatment facilities in the region. This necessitates special consideration of the management of these cancers which are now easily curable in other regions where early presentation is a feature but are still a major cause of cancer fatalities in Africa. Collaboration within the continent and externally would have a big a role to play in the control of these cancers.
doi:10.1016/j.oraloncology.2011.06.079 doi:10.1016/j.oraloncology.2011.06.080 S16. Role of AFROG in improving the management of head and neck cancers in Africa Ntokozo Ndlovu
Sponsored Symposium #6:
Department of Radiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
S17. Patient-related factors associated with poor outcomes André Lopes Carvalho
Introduction: The African continent has a wide variety of head and neck cancers according to the subregions. While in North Africa most of these cancers are as a result of smoking and are commonly the classical squamous cell carcinomas, in Central and Southern Africa the HIV epidemic has changed the cancer scenario and head and neck cancers have not bee spared. Manifestations of Kaposi’s sarcoma and non-Hodgkins lymphoma in the head and neck region is a common feature in the cancer treatment clinic. The region has a limited cancer treatment capacity in general due to limited human and economic resources. Methods: The African Radiation Oncology Group (AFROG) is an organization that aims to promote Radiation Oncology and other health practices relevant to the management of cancer within African countries through exchange of knowledge and technology between African countries, continued education, provision of technical expertise, supporting of prevention, early detection and treatment facilities, promotion of radiation safety and research. There is in particular, a recognition of the burden of head and neck cancers in the African region and the need for strategies to combat this group of cancers. The organization also aims at forming liaisons with other organizations of similar interest internationally to achieve its goals. Results: The major collaborator for AFROG is the International Atomic Energy Agency (IAEA) through its Technical Cooperation Department, the Division of Human Health and the Programme of Action for Cancer Therapy (PACT). Radiation therapy is an important part of the treatment of head and neck cancer. In Africa, patients needing this form of treatment could are likely to constitute a higher proportion that in other parts of the world, this being as a consequence of late presentation when surgery is no longer feasible. Unfortunately this treatment is not as
Department of Head and Neck Surgery, Barretos Cancer Hospital, Barretos, Brazil Brazilian Society of Head and Neck Surgery (BSHNS) Advanced oral cancer per se is related to a poor prognosis. However, the literature has shown that factors related to the patient can influence the outcome and stratify prognostic groups within these patients. The main factors related to the patient that can be associated with prognosis are age, race, education, socioeconomic status, comorbid conditions, performance status, symptom distress, among others. The relationship of those factors and prognosis can be due mainly on how they influence access to a proper treatment, the possibility of performing the standard treatment, besides how physicians are influenced in not delivering the standard treatment. We need to discuss how patient-related factors are associated with outcome in advanced oral cancer patients and mainly what are the possibilities for reverting this scenario in selected cases. doi:10.1016/j.oraloncology.2011.06.081
S18. Treatment of patients with advanced (N2–N3) metastatic lymph nodes Fernando Walder ENT and Head and Neck Surgery Department, The University Federal of São Paulo, Brazil Despite the use of aggressive single or multimodality treatment protocols, patients with advanced cervical metastases, N2 and N3,
S20
Abstracts / Oral Oncology 47 (2011) S15–S27
have a poor prognosis because of their high risk of regional and distal failure. Moreover, N3 class does not allow resectability and curability to be defined. Numerous trials have been carried out in order to improve the oncological outcomes of patients with advanced metastases to the neck using a variety of multimodality therapy. The presence of advanced cervical metastases is a very poor prognostic factor. The combined treatment modality offers better chances of cure than single modality treatment. Surgery followed by radiotherapy or chemo-radiation therapy is an effective and well-standardized approach. The use of planned neck dissection following chemoradiation is still debated. doi:10.1016/j.oraloncology.2011.06.082
S19. Long term cosmetic and functional results of reconstruction using myocutaneous and free flaps Rogério A. Dedivitis Department of Head and Neck Surgery, Hospital das Clínicas, São Paulo School of Medicine University of São Paulo, Brazil Department of Head and Neck Surgery, Fundação Lusíada and Metropolitan University, Santos, Brazil Radical surgery along with radiation therapy remains the treatment of choice for advanced oral cancer. Since surgery is required, a major emphasis is placed on providing successful reconstruction which is intended to maintain both function and appearance. However, it is a difficult and challenging task. Primary closure, skin grafts, fasciocutaneous flaps, myocutaneous flaps and free flaps have been described in order to repair these defects. This choice depends on the site, type and extension of the defect. Furthermore, it depends on the expertise of the surgical staff and its availability for more complex approach, which is particularly troublesome in developing countries. Deterioration of the quality of life and pulmonary, swallowing, speech and cosmetic impairment after treatment can be properly evaluated by means of reliable and valid questionnaires. This evaluation can influence the preoperative decision, as well.
itation of swallowing. A comparison between the oncologic and functional results prior to 1998 and thereafter is the subject of this report. Before 1998 owing to non availability of micro vascular free flap reconstruction options, such mega resections received regional flaps with resection of posterior segment of mandible to facilitate insetting of flap, despite mandibular invasion noted only in 1/4 th of resected specimens. Microscopic positive margins viz. R1 resections were seen in 21% of cases and a loco regional control rate at 2 years was 45%, with almost all the cases (N = 22) done as planned primary surgery followed by adjuvant post op radiotherapy. Swallowing rehabilitation was stormy and required intensive swallowing therapy lasting 2–3 months at the end of which two thirds of patients swallowed thickened liquids and liquids at best without troublesome aspiration. The rest were dependent on some form of enteral alimentation, namely feeding jejunostomy or gastrostomy. Since late 1990s the same operation was carried out in 20 cases of advanced tongue cancer; 14 cases (that did not require segmental resection of mandible) underwent primary surgery with mandibulotomy approach and free micro vascular flap for soft tissue reconstruction and laryngeal elevation. Microscopic positive margins (R1) were seen in 15% and all received post op adjuvant chemoradiotherapy. This group of 14 cases had loco regional control of 65% at 2 years; on the rehabilitative front the final resumption of oral nutrition without significant aspiration was achieved in 12/14 within a period of 4–6 weeks. In 2 of these cases owing to unsuccessful rehabilitation secondary to significant aspiration there was dependence on a G tube. In those that achieved oral alimentation, nature of food consistency at the end of rehabilitation remained the same as in the pre 1998 cohort. Careful patient selection, adoption of mandibulotomy approach with micro vascular free flap reconstruction with laryngeal elevation seem to lend themselves to better local control with satisfactory swallowing sans aspiration in majority. Swallowing therapy under the supervision of expert in such a scenario has made this operation well worth the effort, both oncologically and functionally. doi:10.1016/j.oraloncology.2011.06.084
doi:10.1016/j.oraloncology.2011.06.083 Sponsored Symposium #7 S20. Challenges in rehabilitation after sub-total and total glossectomy with laryngeal preservation Ashok M. Shenoy a, Anand Krishna, Poornima Shenoy, Premalatha, Rahul, Sharath Dept. of Head & Neck Surgery, Kidwai Memorial Institute of Oncology, Bangalore, India Total glossectomy and sub-total glossectomy defined as ‘‘resection with removal of greater than 70% of tongue ‘‘(oral and posterior tongue) with laryngeal preservation despite ipsilateral, hypoglossal and lingual nerve sacrifice is a formidable operation, which is still performed for oncological control owing to lack of comparable alternative treatment strategy for these advanced tumors. This study is a single center experience over 2 decades since 1990, of trends in surgical extirpation of massive lesions (T3 and T4a) that may have initially originated either in anterior two thirds of tongue or tongue base or both. After 1998 there have been several trends adopted largely to facilitate early post surgical rehabil-
a
Visiting Proferssor, Hospital Das Clinicas, Sao Paulo, Brazil, 1996.
S21. Complex issues in cancer of the oral cavity Ashok R. Shaha International Federation of Head and Neck Oncologic Societies (IFHNOS), New York, USA International Federation of Head and Neck Oncologic Societies (IFHNOS) In spite of serious efforts to diagnose cancer of the oral cavity and perform close surveillance, approximately two-thirds of patients still present with locally advanced cancer of the oral cavity. This leaves the physician with several complex issues in the management of cancer of the oral cavity, including locally advanced cancers, involvement of the mandible, management of advanced neck disease, and mandibular reconstruction. Complications, such as osteoradionecrosis which continues to be a major issue after initial radiation therapy or postoperative radiation therapy, will be discussed. A majority of advanced cancers of the oral cavity are best treated with surgery and postoperative radiation therapy. However, a small percentage of patients may receive non-operative therapy.