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Surgical Management of Head and Neck Carcinoma
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Seminars in Oncology Nursing, Vol 25, No 3 (August), 2009: pp 172-182
SURGICAL MANAGEMENT OF HEAD AND NECK CARCINOMA RAYMOND SCARPA OBJECTIVES: To describe surgical approaches to the management of head and neck cancers and discuss postoperative management and challenges in rehabilitation of patients with head and neck cancer. DATA SOURCES: Peer reviewed journals, reference books, research studies. CONCLUSION: Surgical management of tumors in the head and neck is complex and challenging. It is influenced by tumor size, location, previous treatment, and histopathology. Technologic advances have led to better preoperative planning, improved intraoperative interventions, decreased postoperative functional defects, and extended survival in select cases. IMPLICATIONS FOR NURSING PRACTICE: A multidisciplinary oncology team approach to care is essential to successful outcomes. Basic survival skills such as breathing, eating, and communicating are all subject to compromise as a result of the disease process and treatment. KEY WORDS: Head and neck cancer, surgical management, squamous cell carcinoma.
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URGICAL intervention is a significant treatment modality for patients diagnosed with head and neck malignancies. Favorable outcomes are determined by the extent of tumor staging, functional and cosmetic defects, surgical skills, and the experience of a multidisciplinary team. The goals of Raymond Scarpa, DNP, AOCNÒ: Advanced Practice Nurse, Clinical Instructor, Department of Surgery, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey, Newark, NJ. Address correspondence to Dr. Raymond Scarpa, DNP, AOCNÒ, Department of Surgery, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey, 90 Bergen St, DOC, Suite 8100, Newark NJ 07101; e-mail: [email protected] Ó 2009 Elsevier Inc. All rights reserved. 0749-2081/09/2503-$32.00/0. doi:10.1016/j.soncn.2009.05.007
surgical intervention are to improve quality and quantity of life by removing the tumor, restoring function, and preserving aesthetic features. Successful management is greatly influenced by the size and location of the primary tumor, its spread to regional lymph nodes, distant metastasis, and histopathology features. Small, early stage tumors (T1-T2) of the tongue and oral cavity for example, can be treated successfully with surgery alone.1 Treatment selection depends on patient factors, local expertise, availability of appropriate support, and rehabilitation services. Locally advanced tumors of the head and neck area (T3-T4) will likely require combined modalities that include radiation and/or chemotherapy.2 Treatment of locally advanced head and neck cancer continues to change significantly. Improvements in surgical interventions with the use of lasers have led to better functional outcomes with resectable oral lesions.1
SURGICAL MANAGEMENT OF HEAD & NECK CARCINOMA
Postoperative radiation therapy with epidermal growth factor receptor inhibitors and adjuvant chemo-radiotherapy has led to extended survival in this patient population.3 This article reviews the surgical intervention of tumors in the oral cavity and larynx, the various types of neck dissections, and illustrates the unique challenges in pre and postoperative management and rehabilitation.
ORAL CARCINOMA Oral carcinoma is one of the most common forms of head and neck cancers.4 The Surveillance, Epidemiology and End Result (SEER) program of the National Cancer Institute reported an age-adjusted incidence rate of 10.4 per 100,000 per year between 2002 and 2006 for oral cavity and pharyngeal carcinomas. The annual percentage change from 1981 to 2006 reflected a significant decreasing incidence trend of -1.1. Corresponding 5-year survival rates based on localized, regional, distant, and un-staged disease were 82.7%, 54.3%, 31.8%, and 53.4%, respectively. Overall 5-year survival from1999 to 2005 was reported at 62.4%.5 Tumors in this area can arise in the anterior two thirds of the tongue, buccal mucosa, upper or lower alveolar ridge (gingival), floor of the mouth, hard palate, retromolar trigone, or lip.6 Squamous cell carcinoma makes up the large majority of cancers in this region. Salivary gland tumors account for most of the remaining oral cavity cancers. The most common site of carcinoma within the oral cavity is the tongue, which accounts for 20% to 50% of all oral cancers.6 They tend to arise on the lateral borders of the middle third of the tongue, are approximately three times more common in men, and tend to occur between the ages of 50 and 70.7 Risk Factors The important risk factors for oral cancers include tobacco and alcohol abuse. The carcinogens found in tobacco tend to have a synergistic effect when combined with alcohol, thus increasing the risk for development of this disease.7,8 Betel nut chewing, common in south Asia, is another risk for oral carcinoma. Other risk factors, such as poor oral hygiene, are less clearly associated with oral cancer.
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Exposure to oncogenic strains of human papilloma virus (HPV), particularly HPV 16, has also been found to be a risk factor of oral carcinoma.8 Lesions that appear on the lip often present as small, flat, nonhealing ulcerations. Other symptoms include a pink, pearly papule-type lesion on the outer surface or diffuse white patches on the buccal surface of the lip. Cancerous tumors arising on the outer lips may be squamous cell or basal cell carcinomas and are frequently related to sun exposure, lack of sun screen, and tobacco use.9 Diagnosis and Staging Establishing a diagnosis is determined by pathologic confirmation of a suspicious lesion. This can be accomplished by tissue biopsy or in some cases a fine needle aspiration of a suspected lesion. The tissue or cytology specimen is examined by a pathologist to establish a diagnosis. The initial stage at diagnosis is a critical factor for establishing a treatment plan and determining overall prognosis. The American Joint Committee on Cancer TNM Staging System is a site-specific method used for staging cancer based on (T)umor size, (N)ode involvement, and distant (M)etastasis.10 Stage at initial diagnosis is an important predictive factor in survival. The National Comprehensive Cancer Network bases treatment recommendations on this staging classification.2 Physical examination and radiographic imaging, such as computed tomography, magnetic resonance imaging (MRI), and positron emission tomography (PET) are commonly used for accurate preoperative staging and treatment planning. Surgical Resection The most common treatment for both early stage and locally advanced tumors of the oral cavity remains surgery, selectively with the addition of radiotherapy.2 Challenges arise in the surgical management of these patients, especially those with advanced stage disease. These challenges include those related to surgical reconstruction and cancer control. Surgical resection is the most common primary treatment of malignant tongue lesions found in the anterior portion of the tongue. 2 A partial glossectomy (partial removal of the tongue) with or without unilateral or bilateral selective neck dissection is indicated for most tumors that are limited to the anterior two thirds of the tongue.2
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Resection of oral carcinoma typically includes a visible 1 to 2 cm margin of tumor-free tissue around the lesion to ensure complete resection.11 Tumor-free margins may be difficult to establish microscopically as current histopathologic methods are limited. The use of molecular markers may refine current methods.12 The author’s experience has shown that most small- and medium-sized tumors (T1 and T2) can be resected and closed primarily without the need for complex reconstruction. In most cases, there is a good functional result with limited speech and swallowing dysfunction. Previous radiation therapy or the presence of a tracheotomy can limit functional results.13 Functional results can also depend on the skill of the surgeon. Close follow-up is needed to monitor the area for local or distant recurrence. Resection of locally advanced lesions (larger T2, T3, and T4 lesions) can result in a large surgical defect. Locally advanced lesions in the oral cavity may also invade the adjacent mandible, which requires resection of the affected area of bone. Advanced T4 lesions of the tongue that have invaded neurovascular structures, the deep tongue musculature, or that involve both sides of the tongue may result in massive surgical defects.14 Resection of large tumors is associated with poorer functional outcome because of large surgical defects. Reconstruction of these surgical defects exemplifies the surgical challenges. A temporary tracheotomy is usually preformed to secure the airway. A nasogastric feeding tube or gastrostomy tube may be required during the postoperative period to ensure adequate nutritional intake. Reconstructive Options Many reconstructive options are available and are tailored to the individual patient based on the size, location, and tissue type of the surgical defect. Reconstructive options include split thickness skin grafts, pedicled myocutaneous flaps, and recently, the use of microvascular free tissue transfer.15 A split thickness skin graft can be used to reconstruct a small-to-moderate sized soft-tissue defect including the buccal mucosa, gingiva, and floor of the mouth.15 Large soft-tissue defects and defects into the neck and/or overlying skin will require complex reconstruction. A pedicled pectoralis major myocutaneous flap may be used. This type of graft maintains it blood flow from its original site. Radial forearm microvascular free tissue
transfer or other similar fasciocutaneous flaps are commonly performed as well. These flaps tend to be less bulky and more versatile than the pectoralis major flap, with better cosmetic and functional outcomes. However, this type of reconstruction is technically challenging and timeconsuming, as blood supply to the flap requires microvascular anastomosis to vessels in the area.15 Resection of oral carcinoma, which includes a full-thickness resection of a segment of mandible, is best reconstructed with a microvascular free tissue transfer that includes vascularized bone. The fibula, the long thin outer bone of the lower leg, is commonly used to reconstruct segmental defects of a section of the mandible. This type of microvascular free tissue transfer includes bone, muscle, and skin. It can be used in these cases to reconstruct both the bone and soft tissue defects. This helps to maintain dental occlusion and provides well-vascularized bone for osteointegrated dental implants.16 Titanium reconstruction plates are used to secure the sculptured fibula to the remaining mandible, which holds the tissue flap rigidly in place. The morbidity in this type of reconstruction is generally low; two teams can work simultaneously as the fibula is located far from the head and neck region.17 However, this type of reconstruction is timeconsuming and technically challenging. It also requires the patient to have good arterial blood flow to the lower leg. The iliac crest and scapula are other areas of the body where this type of free flap can be harvested, although these procedures are less commonly performed.15 Oral squamous cell carcinoma commonly metastasizes to cervical lymph nodes in the neck. Management of the neck is concurrent with treatment of the oral cancerous lesion.14 Controversy exists regarding management of the neck for early stage lesions in the oral cavity. The risk for metastases to the cervical lymph nodes increases in oral cavity tumors with tumor size and thickness.14 Frequently, patients with early stage disease (T1-2, N0) with no clinically evident lymph node metastases will undergo an ipsilateral selective neck dissection (removal of lymph nodes from the areas of the neck at the highest risk of metastatic tumor) given an estimated 20% to 30% chance of occult lymph node metastases.14 This may help prevent later recurrence of tumor in the cervical lymph nodes requiring additional surgery; however, an overall
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survival benefit has not been proven.14 Patients found to have lymph node metastases at initial presentation should undergo a neck dissection at the time of resection of the primary lesion.2 Postoperative Nursing Care Patients are placed in a postoperative recovery unit until they are stabilized from the withdrawal of anesthesia and mechanical ventilation. Once stabilized they can be transferred to a step down unit, with skilled nursing care, without the need for an intensive care environment. Nursing ratios range from one to two patients per nurse.18 Diligent postoperative monitoring is of particular importance in patients who require a microvascular free tissue reconstruction. Ensuring flap viability is important to secure a successful outcome because the tissue is entirely dependent on the anastomosed artery and vein for inflow and egress of blood.19 Inadequate arterial inflow or venous congestion from inadequate venous drainage or venous thrombosis can lead to flap failure if not recognized immediately. However, prompt recognition of a compromised flap allows for surgical repair before irreversible damage occurs to the flap tissue. Spiegel and Polat19 reported a 6.8% return rate of patients to the operating room to address flap complications. Several techniques have been used to monitor blood flow in microvascular free flaps. Arterial flow can be monitored by handheld Doppler ultrasound. Capillary refill in 1 to 2 seconds is also known as a reliable indicator of arterial flow. However, venous congestion is the most common cause for flap failure and can be more difficult to Instantaneous capillary refill recognize.19 (swelling and bluish discoloration of the flap) can be signs of venous congestion. The nurse should assess capillary refill and color of the flap at least every 1 to 2 hours in the immediate postoperative period.19 This can be challenging in the oral cavity where the flap skin may be difficult to visualize. A change in color or refill characteristics warrants immediate intervention, which may include returning the patient to the operating room to revise the microvascular anastomosis and remove any blood clots obstructing blood flow. When venous congestion cannot be corrected surgically or there is a delay in bringing the patient to the operating room, initiating medicinal leech therapy can help ensure survival of the flap.20 Patients are often placed on anticoagulants postoperatively,
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such as aspirin and intravenous dextran, and will need to be monitored for excessive bleeding.19 Monitoring the output and consistency from drains placed in the surgical areas of the neck is a critical factor in patient care. An increase output of an odorless milky consistency, especially after oral intake has started, may indicate a chyle fistula. Chyle is composed of lymphatic fluids and fat globules that line the intestine. The production of chyle is increased in relation to oral intake of fats and triglycerides. Although rare, management of this type of fistula may be conservative by limiting dietary fats and medium chain triglycerides. If managing diet is unsuccessful, surgical repair is indicated.21 A cloudy odorous type of output may indicate a salivary fistula. This type of fistula has an extremely variable incidence, ranging from 5% to 65%.22 Drainage should be sent for amylase analysis if a salivary fistula is suspected.23 Conservative management includes adequate continued drainage, neck compression, antibiotics, and frequent dressing changes.22 Surgical repair may be indicated if conservative measures prove unsuccessful. Chemotherapy/Radiation Therapy Primary treatment with combined chemotherapy and radiation therapy or radiation therapy alone is used for locally advanced tumors that are unresectable because of large tumor size larger 8 cm, carotid artery encasement, and/or pre-vertebral fascia involvement.24,25 Combined chemotherapy and radiation therapy may also be considered when surgical resection would result in overwhelming functional and cosmetic defects or in patients who are not candidates for surgery because of underlying co-morbid medical conditions. The addition of chemotherapy to radiation therapy after surgery has been shown to decrease recurrence and improve survival in selected cases with poor prognostic features. These poor prognostic features include large tumor size, close or positive surgical margins, histopathologic features (such as perineural invasion or vascular invasion), advanced nodal disease, and extra-capsular extension of tumor involving the cervical lymph nodes of the neck.24 Salvage Surgery Patients with residual or recurrent cancer after chemotherapy and radiation therapy may be
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candidates for salvage surgery. However, healing is often delayed by the effects of chemoradiation, and surgery is technically more difficult. This leads to a higher risk of wound breakdown and salivary fistula formation because of compromised tissue vascularity, tissue fibrosis, compromised nutritional status, poor blood supply, and impaired lymphatic drainage caused by prior treatment.26 Salvage surgery is viewed as a last chance for cure. This can be a difficult concept for the patient and family to comprehend, especially when chance for cure is minimal. Locoregional control and survival rates for the patient undergoing salvage surgery after chemoradiation therapy are not encouraging.27 One non-randomized retrospective study looked at 204 patients that received chemoradiation, 38 recurred and underwent salvage surgery. Overall survival was reported at 60% for 12 months and 27% at 2 years. Locoregional control was 42% at 2 years; surgical morbidity was reported at 24%. Lower survival rates were seen with advanced (N3) neck disease.27 Gokhale and Lavertu26 reviewed several studies on complications and outcomes in this select group of patients and found similar findings in complication rates, especially when salvage surgery was performed at the primary site of disease. Nursing Implications. Patients who have had radiation therapy or combined chemotherapy/ radiation therapy before salvage surgery pose a unique set of postoperative concerns. Surgical morbidities include wound breakdowns in the irradiated field of the neck causing tissue necrosis, infection, bleeding, and salivary fistulas.27 This can result in exposure of the carotid artery, which requires protection with vascularized tissue to prevent rupture. As tissue continues to breakdown in the surgical area, exposure of reconstructive hardware and bone can increase the risk for infection and further wound breakdown. The use of drains, antibiotics, oral hygiene, packing the wound, and wound vacuum dressings can help decrease the risk of infection and promote formation of granulation tissue to support healing.28 During an extended postoperative recovery period the patient may have difficulty communicating, be tracheostomy dependent (for secretion and airway management), be reliant on enteral feeding, and have extreme facial disfigurement. Withdrawal from alcohol during this period can also complicate and prolong recovery. There is
a significant need for a multidisciplinary team approach to assist the patient and their support systems with adjustment to these issues.26 In patients that have undergone extensive head and neck surgery, the need for a tracheostomy is a critical initial step in securing the airway. Postoperative factors to be considered before removing a tracheostomy (decannulation) are the patients’ level of consciousness, effectiveness of cough to clear secretions, and resolution of any postoperative swelling in the upper aerodigestive tract.29 A trial period of capping the tracheotomy tube can give some insight to readiness for decannulation. A speech pathologist can assist with communication needs and determine the patient’s ability to tolerate oral intake safely and avoid aspiration. Consultation with a registered dietician can provide information on appropriate caloric intake to promote healing.30
LARYNGEAL CARCINOMA Laryngeal carcinoma is the second most common form of head and neck cancer. It accounted for 12,250 new cases in the United States in 2008. There were 3,670 associated deaths.31 The age adjusted incidence rate was 3.5 per 100,000 per year. Median age at diagnosis was 65 years. It is approximately six times more common in men.32 Risk factors for development of this form of cancer include tobacco and/or alcohol abuse. Other factors include exposure to wood dust, nitrogen mustard, asbestos, and nickel.33 The larynx is a complex neuromuscular organ that has three main functions: airway protection, phonation, and respiration. The larynx acts like a sphincter, providing airway protection during swallowing. To avoid aspiration, the true vocal cords, false cords, and epiglottis/aryepiglottic folds closed and the larynx is raised during swallowing. The true vocal cords contact each other to produce sound when air passes between them. Phonation occurs when this sound is converted to recognizable words by muscle contractions/relaxation in the oral cavity and tongue.34 The larynx is divided into the supraglottic, glottic, and subglottic areas. Tumors arising in the supraglottic area tend to cause dysphagia that can result in aspiration. Patients with supraglottic tumors often remain asymptomatic for some time and tend to present with advanced disease.35 Tumors in the glottic area are more common and localized.
SURGICAL MANAGEMENT OF HEAD & NECK CARCINOMA
Patients with tumors in this area tend to present with voice changes or hoarseness. Lesions in this area can easily compromise the airway. Increased shortness of breath or difficulty breathing makes a tracheotomy necessary to improve breathing. Patients with glottic lesions often present earlier because of symptoms of hoarseness or difficulty breathing. Lesions presenting in the subglottic area are rare and account for about 1% to 8% of all laryngeal cancers. They are usually extensions of lesions arising in the supraglottic or glottic area.36 Treatment of laryngeal cancer is based on tumor stage at initial presentation.2 The majority of laryngeal cancers are squamous cell carcinoma. The goal of laryngeal cancer management is to maximize cancer control while preserving functions of airway protection, swallowing, and voice production. Early Stage Laryngeal Cancer (T1/T2) Early stage laryngeal cancer is generally treated with either radiation therapy or surgery alone.2 Radiation therapy and surgery seem to have similar survival rates for treatment of early glottic and supraglottic cancer; however, there are no randomized controlled trials that compare conservative surgery with radiation therapy in this patient population.37 Radiation therapy for glottic cancer is usually confined to a small field because the risk of lymph node metastases is very low. Radiation for supraglottic cancer incorporates a larger field that includes the lateral neck on both sides due to a high risk of bilateral lymph node metastases.37 Surgery for early stage laryngeal cancer generally does not require complete removal of the larynx. Surgical options for early glottic carcinoma include endoscopic excision of the lesion.2 This can be accomplished by cordectomy (removal of the vocal cord) if the lesion does not extend to the anterior commissure or arytenoid cartilage. Open partial laryngectomy, sometimes referred to as a vertical hemilaryngectomy, removes approximately half of the larynx and is one of several partial laryngectomy procedures. Tumor extension to certain areas, such as the posterior commissure, arytenoid cartilage, and thyroid cartilage, are considered contraindications to this type of surgery.34 Surgical management of early supraglottic cancer is generally performed by open supraglottic laryngectomy, which removes the upper part of the larynx but preserves the true vocal cords and
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arytenoid cartilages. Supraglottic cancers have a high incidence of lymph node metastases; therefore, neck dissection and postoperative radiation therapy are often used.35 Cancer control rates are similar to that of radiation therapy alone. The decision to perform primary radiation therapy or surgery is based on anticipated functional outcome, because cancer control rates are similar.34 Superficial cancers of the glottic larynx limited to one vocal cord may be easily removed endoscopically with excellent voice outcome.38 More extensive lesions require resection of more tissue, and may be associated with poorer voice quality than radiation therapy. Open partial laryngectomy procedures are often associated with a significant impact on voice quality and swallowing, especially with vertical partial laryngectomy and the supraglottic laryngectomy.34 These procedures are less commonly performed today for these reasons. Newer techniques for surgical resection of early stage glottic or supraglottic laryngeal cancers along with selective neck dissection may change the treatment choice for some patients. Transoral endoscopic procedures, so-called minimal access surgery, have been used in recent years with excellent reported oncologic and functional outcomes in highly selected patients.38 These techniques include transoral CO2 laser resection and, more recently, transoral robotic-assisted surgery. Small, well-circumscribed lesions in the supraglottis and glottic larynx, as well as selected larger tumors, can be resected using the laser.39 Reported benefits include excellent functional outcome and avoidance of tracheostomy in most cases. Swallowing can be affected by the extent of laser resection and aspiration can occur postoperatively.40 Roh et al40 reported 3-year locoregional control, disease-free survival, and overall survival as 81%, 71%, and 79%, respectively. However, laser surgery is time-consuming, technically challenging, and resource intensive. It is currently performed only in specialized centers. Advanced Laryngeal Cancer (T3/T4) Management of advanced stage laryngeal cancers typically requires multimodality treatment. The previously accepted treatment for advanced laryngeal cancer was total laryngectomy with or without postoperative radiation therapy. However, in recent years, nonsurgical management with combined chemotherapy and radiation therapy, also known as ‘‘organ preservation,’’ is more common.2 When
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total laryngectomy is required, it involves a surgical procedure that removes the entire larynx. This procedure separates the upper aerodigestive tract from the trachea. Air no longer passes into the mouth or nose. The patient is left with a permanent tracheal stoma in the neck for breathing. This results in a loss of smell, which decreases the sense of taste. Patients no longer can sniff, sneeze, or blow their nose. They also lose their ability to phonate. Indications for this surgical procedure are reserved for locally advanced laryngeal lesions in patients ineligible for chemotherapy and radiation and for recurrence following primary treatment with chemoradiation. It is not indicated for patients with distant metastatic disease or with severe co-morbid medical conditions.41 The patient who has a total laryngectomy and permanent tracheal stoma will encounter numerous issues (ie, communication challenges, changes in activities of daily living [showering/bathing routines], potential oral and airway dryness, concerns about dust and environmental irritants, and changes to social and outdoor recreational activities [eg, swimming, boating]). Voice rehabilitation can be accomplished in several ways, including use of an electrolarynx, use of tracheo-esophageal prosthesis, or esophageal speech.35 The Cooperative Studies Program of the Veterans Affairs Laryngeal Cancer Study Groups’ landmark study reported on the ability to preserve the larynx in patients with advanced laryngeal cancer.42 This prospective randomized study compared patients treated with surgery with those treated with sequential chemotherapy and radiation, with surgery reserved for non-responders to chemotherapy. They found that the 2-year survival rate was 68% for both groups. At 3 years, 40% of patients who received chemoradiation remained disease-free with an intact larynx. Although the chemotherapy and radiation protocols have evolved since the time of this study, the finding established the trend toward organ preservation in the management of advanced laryngeal cancer. The aim of this type of treatment is to avoid a permanent tracheal stoma and maintain the normal function of the larynx while still controlling the cancer. Chemoradiation is now accepted as a treatment alternative for patients who require a total laryngectomy.33 Its use has been extended to patients with less extensive tumors who may be candidates for partial laryngectomy. However, chemoradiation therapy is associated with significant side
effects, including acute mucositis, long-term xerostomia, and dysphasia. Management with chemoradiation requires careful monitoring. Salvage surgery will be indicated if there is residual or recurrent tumor. Salvage surgery often requires total laryngectomy, even in patients who may have been candidates for partial laryngectomy before treatment. The functional outcome for patients treated with chemoradiation is often excellent. One study found better long-term quality-of-life scores associated with physical functioning and social interactions in patients treated with chemoradiation as compared with those treated with total laryngectomy with voice prosthesis.43 They reported fewer problems with pain, speech, breathing, and sleep disturbances; however, some patients had severe swallowing difficulty and required long-term gastrostomy tubes and some patients with airway obstruction required long-term tracheostomy. In these cases, the larynx may have been preserved, but function was not. The role of chemoradiation in patients with extensive local tumor, especially with thyroid cartilage invasion, has not been clearly established.14 It appears that the likelihood of success of chemoradiation is decreased in such cases, although it may also be decreased with primary surgery as well. Unfortunately, no direct comparative data yet exist in this subgroup of patients. The use of robotic-assisted surgery is investigational, but may play an important role in enhancing surgical accuracy and performance. Robotics in laryngeal surgery may prove to overcome some of the shortcomings of endoscopic laser surgery, such as limitation of visual fields, increased degree of instrumentation freedom, and elimination of tremor.44 The use of robotics in head and neck surgery, although feasible, may be inhibited by its high cost and need for specialized training. Further research is needed and must include prospective randomized trials to determine efficacy and safety. Benefits to patients and health care systems need to be evaluated to justify the expense.45 Nursing Implications Immediate postoperative care focuses on maintaining a patent airway, nutrition, fluid and electrolyte balance, drain output, and communication. Suctioning and frequent changes of the tracheotomy/laryngectomy tube’s inner cannula help to
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FIGURE 1. Classifications of Lymph Node Groups by Level and Associated Primary Risk Sites49 Level I Submental – Tumors originating from the floor of mouth, anterior tongue, mandibular alveolar ridge, and lower lip Submandibular - Tumors originating from the oral cavity, nasal cavity, midface soft tissue, and submandibular gland Level II Upper Jugular Area - Tumors originating from the nasopharynx, hypopharynx, oropharynx, larynx, oral cavity nasal cavity, and parotid gland II (a): Upper one-half of the superior jugular area II (b): Lower one-half of the upper jugular area The structure separating II (a) from II (b) is the spinal accessory nerve, the lower boarder of II (a) Level III Middle Jugular Area - Tumors originating from the nasopharynx, hypopharynx, oropharynx, larynx and oral cavity Level IV Lower Jugular Area – Tumors arising from the hypopharynx, upper esophagus and larynx Level V Posterior Triangle – Tumors arising from the nasopharynx and oropharynx V (a) Includes lymphatics that follow the spinal accessory nerve V (b) Includes lymphatics that lie along the transverse cervical artery Level VI Anterior Compartment of the Neck – Tumors arising from the thyroid gland, cervical esophagus, glottic and subglottic areas of the larynx and pyriform sinuses
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keep the airway free from developing a mucous plug. A temporary nasogastric feeding tube is usually placed at the time of surgery to allow for nutritional intake and for the pharynx and esophagus to heal. Some patients require free flaps such as laryngopharyngectomy and then corresponding care is required. A writing pad with pen or pencil can provide a simple way for patients to communicate, but this can be frustrating for both the patient and staff, especially if patients are illiterate or English is not their first language. A communication board, picture board, or cards can provide a less frustrating way to communicate immediate needs. Patient education will include stomal cleaning and secretion management. Communication rehabilitation for patients having had a total laryngectomy will focus on several options. A tracheo-esophageal puncture can be preformed for placement of a valve.46 The surgical procedure creates a tract between the posterior wall of the trachea and the anterior wall of the esophagus within the tracheal stoma. A one-way valve is placed into the created tract. Air from the trachea is pushed through the valve and into the esophagus and pharynx when the patient covers the stoma and attempts to exhale. The air vibrates the upper pharynx and is modulated by the tongue and pharynx, thereby creating speech. This procedure can be performed at the time of laryngectomy or at a second surgery. Although the quality of the speech is monotone, it is easily understood even over the telephone. Cleaning of the speech prosthesis and periodic changes of the prosthesis are required. A similar technique for communication is esophageal speech. The patient swallows air and is taught to control the release of that air, almost like a burp, to vibrate tissues in the pharynx causing sound. This technique can be difficult for most patients to perform without the assistance of a speech language pathologist. A common method for communication after laryngectomy is the use of an electrolarynx, a mechanical device that produces vibrations and sound. The device is placed in an area on the neck where the vibrations and sound travels into the oral cavity. The vibrations and sound are converted to words by the muscles in the pharynx and tongue. Oral adapters are available for patients that have severe fibrosis of the soft tissues in the neck caused by surgical scarring and radiation therapy. The speech quality is mechanical sounding, but is easy for most patients to learn and does not require a surgical
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procedure or upkeep. The electrolarynx can be permanent or used temporarily, until a tracheoesophageal puncture is performed.46
METASTATIC NECK DISEASE One of the first individuals to describe the lymphatic drainage in the head and neck was Dr. Henri Rouviere, who set the groundwork for future work in this area.35 Robbins et al47,48 have identified levels of lymphatics in the head and neck and identified the primary sites associated with risk for metastatic disease. Figure 1 illustrates these levels and associated primary tumor sites. Lymphatic metastases occur at predictable levels of the neck depending on the site of the primary tumor. Lymph nodes that are involved with tumor may be contained within the lymph node or include extra capsular extension into nearby nerves, salivary glands, muscles, and blood vessels. The lymphatics and various other structures must be treated to avoid recurrence and spread of disease. The removal of the cervical lymph nodes involves a neck dissection or cervical lymphadenectomy. The indication for and the extent of a neck dissection, concurrent with primary tumor resection, is determined by the size and site of the primary tumor, presence and extent of obvious metastatic neck disease, or estimated risk of metastases to the neck when there is no obvious metastasis.47,49 A neck dissection may also be performed after chemoradiation when there is suspected residual cancer involving lymph nodes present on MRI or PET scan or in patients with advanced neck disease at presentation. Cure rates drop by almost 50% in patients with metastatic neck disease compared with patients with similar sized primary tumors without metastatic neck disease.14 Surgical procedures used to perform the neck dissection are: the radical neck dissection, modified radical neck dissection, extended radical neck dissection, and the selective neck dissection. See Table 1 for a description of these procedures. Radical neck dissection can be combined with resection of the primary site or following primary radiation therapy. It is indicated when tumor is extensive or in the presence of extra capsular extension.49 Cosmetic alterations in the contour of the neck occur as a result of this procedure. Limited range of motion of the shoulder resulting from removal of the spinal accessory nerve can occur. This can lead to chronic pain, shoulder
droop, and atrophy of the trapezius muscle along with shoulder fixation. An extended radical neck dissection is reserved for extensive disease that has invaded additional lymphatic and nonlymphatic structures not already included in the radical neck dissection.50 This may include skin, carotid artery, vagus, hypoglossal nerve, and additional lymphatic groups such as mediastinal, parapharyngeal, or paratracheal. Cosmetic and functional defects are dependent on what is resected at the time of surgery. Speech and swallowing dysfunctions can occur when the vagus and/or hypoglossal nerves are sacrificed.50 The modified radical neck dissection is indicated for a patient with metastatic disease in the neck that does not involve or adhere to this nonlymphatic structure.49 Problems related to trapezius muscle weakness (eg, raising the arm above the shoulder) can be avoided or decreased in many patients by preserving this nerve. The selective neck dissection is commonly used for patients without obvious cervical lymph node metastasis, and is often referred to as an elective neck dissection. Some advocate its use in patients with known lymph node metastases when there is a limited degree of neck disease.49 Previous terminology described such procedures as suprahyoid neck dissection, supraomohyoid neck dissection, lateral neck dissection, anterior neck dissection, and posterolateral neck dissection. A uniform terminology was suggested by The American Head and Neck Society (AHNS) and the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Committee for Head and
TABLE 1. Types of Neck Dissection
Radical neck dissection
Modified radical neck dissection
Selective neck dissection
Removes all lymphatics from levels I through V, the sternocleidomastoid muscle, the jugular vein, submandibular gland, and spinal accessory nerve Removal of all lymphatics from levels I, through V with preservation of one or more non-lymphatic structures (eg, spinal accessory nerve, jugular vein or sub-mandibular gland) Removes lymph nodes from selected levels only, rather than all V levels. The levels removed depends on primary cancer site and lymph nodes at greatest risk for metastases
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Neck Surgery and Oncology. The 2008 Consensus Statement included recommendations that the term ‘‘selective neck dissection’’ be used with specific notation to the levels and/or sublevels of lymphatics removed.48 For example, a practitioner planning a selective neck dissection for a T2 tongue carcinoma would include levels I through IV. New recommendations suggest that it be reported as a selective neck dissection, sublevels Ib, IIa, III, and IV, rather than an extended supraomohyoid neck dissection. Nursing Implications Patients need to be informed of the potential complications that may occur after neck dissections. Complications include bleeding, lymphatic leak, nerve injury, wound infection, chyle fistula,
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skin flap necrosis, and carotid artery rupture. Cosmetic deformity, shoulder pain, and dysfunction are of major concern. Physical, psychosocial, speech, and swallowing rehabilitation are necessary components of care, which are met through a multidisciplinary approach.
CONCLUSION Surgical management of tumors in the head and neck is complex and challenging. It is influenced by tumor size, location, previous treatment, and histopathology. Technologic advances have led to better preoperative planning, improved intraoperative interventions, decreased postoperative functional defects, and extended survival in select cases.
REFERENCES 1. Yao M, Epstein JB, Modi BJ, et al. Current surgical treatment of squamous cell carcinoma of the head and neck. Oral Oncology 2006;43:213-223. 2. Forastiere AA, Ang KK, Brizel D, et al. Head and neck cancers. J Natl Compr Canc Netw 2008;6:646-695. 3. Seiwert TY, Cohen EEW. State- of- the- art management of locally advanced head and neck cancer. Br J Cancer 2005;92: 1341-1348. 4. Spencer KR, Ferguson JW, Wiesenfeld D. Current concepts in the management of oral squamous cell carcinoma. Austr Dent J 2002;47:284-298. 5. Surveillance Epidemiology and End Results stat fact sheet on oral cavity and pharynx cancer. Available at: http://seer.cancer.gov/statfacts/html/oralcav.html. (accessed April 29, 2009). 6. Sharma PK, Schuller DE, Baker SR. Malignant neoplasms of the oral cavity. In: Cummings CW, Fredrickson JM, Harker CA, Krause CJ, Richardson MA, Schuller DE, eds. Otolaryngology-head and neck surgery. 3rd ed. St. Louis, MO: Mosby; 1998: pp. 1430-1443. 7. Worden FP, Ha H. Controversies in the management of oropharynx cancer. J Natl Compr Canc Netw 2008;6:707-714. 8. Johnson N. Tobacco use and oral cancer: a global perspective. J Dent Educ 2001;65:328-339. 9. National Cancer Institute. CancerWeb: prevention of oral cancer 208/07490: summary of evidence. Available at: http:// cancerweb.ncl.ac.uk/cancernet/307490.html. (accessed April 29, 2009). 10. American Joint Committee on Cancer. Cancer staging manual. 6th ed. Philadelphia, PA: Lippincott Raven; 2002. 1769. 11. Bradley PJ, MacLennan K, Brakenhoff RH, et al. Management of oral squamous cell carcinoma treated with inadequate excisional biopsy. J Oral Maxillofac Surg 2001; 59:1007-1010. 12. Bradley PJ, MacLennan K, Brakenhoff RH, et al. Status of primary surgical margins in squamous head and neck. Curr Opin Otolaryngol Head Neck Surg 2007;15:74-81.
13. Kazi R, Prasad V, Venkitaraman R, et al. Questionnaire analysis of swallowing-related outcomes following glossectomy. ORL J Otorhinolaryngol Relat Spec 2008;70:151155. 14. Espat J, Carew JF, Shah J. Cancers of the head and neck. In: Bland KI, Daly JM, Karakousis CP, eds. Surgical oncology contemporary principles & practice. New York: McGraw-Hill; 2001: pp. 519-544. 15. Neligan PC, Gullane PJ, Gilbert RW. Functional reconstruction of the oral cavity. World J Surg 2003;27:865–862. 16. Ord RA, Blanchaert RH. Current management of oral cancer: a multidisciplinary approach. J Am Dent Assoc 2001; 132:19-23. 17. Smith JE, Blackwell K, Ducic Y. Mandibular reconstruction plating. Available at: http://www.emedicine.com/ent/TOPIC743.HTM. (accessed November 21, 2008). 18. Bradley PJ. Should all head and neck cancer patients be nursed in intensive therapy units following major surgery? Curr Opin Otolaryngol Head Neck Surg 2007;15:63-67. 19. Spiegel JH, Polat JK. Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope 2007;117:485-490. 20. Chepeha D, Nussenbaum B, Bradford C, et al. Leech therapy for patients with surgically unsalvageable venous obstruction after revascularized free tissue transfer. Arch Otolaryngol Head Neck Surg 2002;128:960-965. 21. Tessier DJ, Williams RA. Chyle fistula. Available at: http:// emedicine.medscape.com/article/190025-print. (accessed May 3, 2009). 22. Qureshi SS, Chaturvedi P, Pai PS, et al. A prospective study of pharyngocutaneous fistulas following total laryngectomy. J Cancer Res Ther 2005;1:51-56. 23. Morton RP, Mehanna H, Hall FT, et al. Prediction of pharyngocutaneous fistula after laryngectomy. Otolaryngol Head Neck Surg 2007;136(Suppl1):s46-s49. 24. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for
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locally advanced head and neck cancer. N Engl J Med 2004;350: 1945-1952. 25. Kohno N, Kitahara S, Tamura E, et al. Concurrent chemoradiotherapy with low-dose cisplatin plus 5-fluorouracil for the treatment of patients with unresectable head and neck cancer. Oncolgy 2002;63:226-231. 26. Gokhale AS, Lavertu P. Salvage surgery after chemoradiation of head and neck cancer: complications and outcomes. Curr Oncol Rep 2001;3:72-76. 27. Richey LM, Shores CB, George J, et al. The effectiveness of salvage surgery after the failure of primary concomitant chemoradiation in head and neck cancer. Otolaryngol Head Neck Surg 2007;136:98-103. 28. Hyman J, Disa JJ, Cordiero PG, et al. Management of salivary fistulas after microvascular head and neck reconstruction. Ann Plast Surg 2006;57:270-273. 29. Stelfox HT, Crimi C, Berra L, et al. Determinants of tracheostomy decannulation: an international survey. Crit Care 2008;12:R26. 30. Dingman C, Hegedus PD, Likes C, et al. A coordinated, multidisciplinary approach to caring for the patient with head and neck cancer. J Support Oncol 2008;6:125-131. 31. American Cancer Society. Cancer facts and figures 2008. Atlanta, GA: American Cancer Society; 2008. 4-5. 32. Surveillance Epidemiology and End Results stat fact sheet on larynx cancer. Available at http://seer.cancer.gov/statfacts/html/laryn.html. (accessed May 1, 2009). 33. Conley BA, Forastiere AA, Gius D, et al. Head and neck cancer. In: Abraham J, Allegra CJ, Gulley J, eds. Bethesda Handbook of Clinical Oncology. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005: pp. 3-31. 34. Bailey BJ. Vertical partial laryngectomy and laryngoplasty. In: Bailey BJ, ed. Head and Neck Surgery – Otolaryngology. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001;1469-1482. 35. Scarpa R, Zevallos J. Surgical management of head and neck malignancies. In: Clarke LK, Dropkin MJ, eds. SiteSpecific Cancer Series Head and Neck Cancer. Pittsburgh, PA: Oncology Nursing Society; 2006;49-61. 36. Su W, Jen Y, Neih S. Multifocal carcinoma of the larynx presenting as subglottic carcinoma. Eur Arch Otorhinolaryngol 2003;260:211-215. 37. Scottish Intercollegiate Guidelines Network. Diagnosis and management of head and neck cancer: a national clinical guideline. Available at: http://www.sign.ac.uk/pdf/sign90.pdf. (accessed November 21, 2008).
38. Roh JL, Kim D-H, Kim SY, et al. Quality of life and voice in patients after laser cordectomy for T1 and T2 glottic carcinomas. Head Neck 2007;29:1010-1016. 39. Werner JA, Dunne AA, Folz BJ, et al. Transoral laser microsurgery in carcinomas of the oral cavity, pharynx, and larynx. Cancer Control 2002;9:379-386. 40. Roh JL, Kim D-H, Kim SY, et al. Quality of life and voice in patients after transoral laser surgery for supraglottic carcinoma. J Surg Oncol 2008;98:184-189. 41. Gopal H, Frankenthaler R, Fried MP. Advanced cancer of the larynx. In: Bailey BJ, ed. Head and Neck Surgery – Otolaryngology. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001: pp. 1505-1522. 42. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991;324:1685-1690. 43. Boscolo-Rizzo P, Maronato F, Marchiori C, et al. Long-term quality of life after total laryngectomy and postoperative radiotherapy verses concurrent chemoradiotherapy for laryngeal preservation. Laryngoscope 2008;118: 300-306. 44. Hillel AT, Kapoor A, Simaan N, et al. Applications of robotics for laryngeal surgery. Otolaryngol Clin North Am 2008;41:781-791. 45. Lanfranco AR, Castellanos AE, Desai JP, et al. Robotic surgery: a current perspective. Ann Surg 2004;239:14-21. 46. Turcotte A, Wilson A, Harris J, et al. Listeners’ social perception of speakers after treatment for laryngeal cancer. Can J Speech Language Pathol Audiol 2009;33:24-33. 47. Robbins KT. Pocket Guide to Neck Dissection Classification and TMN Staging of Head and Neck Cancer. 2nd ed. Alexandra, VA: American Academy of Otolaryngology-Head and Neck Surgery Foundation; 2001. 48. Muller CD, Newlands S, Quinn FB, et al. Neck dissection: Classifications, indications and techniques. 2002; Paper presented at the University of Texas Medical Branch Grand Rounds on January 16, 2002. Available at: http://www.utmb.edu/otoref/ Grnds/Neck-Dissection-020116/Neck-Dissection-020116.pdf. (accessed May 6, 2009). 49. Robbins KT, Shaha AR, Medina JE, et al. Consensus statement on the classification and terminology of neck dissection. Arch Otolaryngol Head Neck Surg 2008;134: 536-538. 50. Shah JP, Patel SG. Head and neck surgery and oncology. 3rd ed. St. Louis, MO: Mosby; 2003; 353-395.
Seminars in Oncology Nursing, Vol 25, No 3 (August), 2009: pp 172-182
SURGICAL MANAGEMENT OF HEAD AND NECK CARCINOMA RAYMOND SCARPA OBJECTIVES: To describe surgical approaches to the management of head and neck cancers and discuss postoperative management and challenges in rehabilitation of patients with head and neck cancer. DATA SOURCES: Peer reviewed journals, reference books, research studies. CONCLUSION: Surgical management of tumors in the head and neck is complex and challenging. It is influenced by tumor size, location, previous treatment, and histopathology. Technologic advances have led to better preoperative planning, improved intraoperative interventions, decreased postoperative functional defects, and extended survival in select cases. IMPLICATIONS FOR NURSING PRACTICE: A multidisciplinary oncology team approach to care is essential to successful outcomes. Basic survival skills such as breathing, eating, and communicating are all subject to compromise as a result of the disease process and treatment. KEY WORDS: Head and neck cancer, surgical management, squamous cell carcinoma.
S
URGICAL intervention is a significant treatment modality for patients diagnosed with head and neck malignancies. Favorable outcomes are determined by the extent of tumor staging, functional and cosmetic defects, surgical skills, and the experience of a multidisciplinary team. The goals of Raymond Scarpa, DNP, AOCNÒ: Advanced Practice Nurse, Clinical Instructor, Department of Surgery, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey, Newark, NJ. Address correspondence to Dr. Raymond Scarpa, DNP, AOCNÒ, Department of Surgery, Division of Otolaryngology, University of Medicine and Dentistry of New Jersey, 90 Bergen St, DOC, Suite 8100, Newark NJ 07101; e-mail: [email protected] Ó 2009 Elsevier Inc. All rights reserved. 0749-2081/09/2503-$32.00/0. doi:10.1016/j.soncn.2009.05.007
surgical intervention are to improve quality and quantity of life by removing the tumor, restoring function, and preserving aesthetic features. Successful management is greatly influenced by the size and location of the primary tumor, its spread to regional lymph nodes, distant metastasis, and histopathology features. Small, early stage tumors (T1-T2) of the tongue and oral cavity for example, can be treated successfully with surgery alone.1 Treatment selection depends on patient factors, local expertise, availability of appropriate support, and rehabilitation services. Locally advanced tumors of the head and neck area (T3-T4) will likely require combined modalities that include radiation and/or chemotherapy.2 Treatment of locally advanced head and neck cancer continues to change significantly. Improvements in surgical interventions with the use of lasers have led to better functional outcomes with resectable oral lesions.1
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Postoperative radiation therapy with epidermal growth factor receptor inhibitors and adjuvant chemo-radiotherapy has led to extended survival in this patient population.3 This article reviews the surgical intervention of tumors in the oral cavity and larynx, the various types of neck dissections, and illustrates the unique challenges in pre and postoperative management and rehabilitation.
ORAL CARCINOMA Oral carcinoma is one of the most common forms of head and neck cancers.4 The Surveillance, Epidemiology and End Result (SEER) program of the National Cancer Institute reported an age-adjusted incidence rate of 10.4 per 100,000 per year between 2002 and 2006 for oral cavity and pharyngeal carcinomas. The annual percentage change from 1981 to 2006 reflected a significant decreasing incidence trend of -1.1. Corresponding 5-year survival rates based on localized, regional, distant, and un-staged disease were 82.7%, 54.3%, 31.8%, and 53.4%, respectively. Overall 5-year survival from1999 to 2005 was reported at 62.4%.5 Tumors in this area can arise in the anterior two thirds of the tongue, buccal mucosa, upper or lower alveolar ridge (gingival), floor of the mouth, hard palate, retromolar trigone, or lip.6 Squamous cell carcinoma makes up the large majority of cancers in this region. Salivary gland tumors account for most of the remaining oral cavity cancers. The most common site of carcinoma within the oral cavity is the tongue, which accounts for 20% to 50% of all oral cancers.6 They tend to arise on the lateral borders of the middle third of the tongue, are approximately three times more common in men, and tend to occur between the ages of 50 and 70.7 Risk Factors The important risk factors for oral cancers include tobacco and alcohol abuse. The carcinogens found in tobacco tend to have a synergistic effect when combined with alcohol, thus increasing the risk for development of this disease.7,8 Betel nut chewing, common in south Asia, is another risk for oral carcinoma. Other risk factors, such as poor oral hygiene, are less clearly associated with oral cancer.
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Exposure to oncogenic strains of human papilloma virus (HPV), particularly HPV 16, has also been found to be a risk factor of oral carcinoma.8 Lesions that appear on the lip often present as small, flat, nonhealing ulcerations. Other symptoms include a pink, pearly papule-type lesion on the outer surface or diffuse white patches on the buccal surface of the lip. Cancerous tumors arising on the outer lips may be squamous cell or basal cell carcinomas and are frequently related to sun exposure, lack of sun screen, and tobacco use.9 Diagnosis and Staging Establishing a diagnosis is determined by pathologic confirmation of a suspicious lesion. This can be accomplished by tissue biopsy or in some cases a fine needle aspiration of a suspected lesion. The tissue or cytology specimen is examined by a pathologist to establish a diagnosis. The initial stage at diagnosis is a critical factor for establishing a treatment plan and determining overall prognosis. The American Joint Committee on Cancer TNM Staging System is a site-specific method used for staging cancer based on (T)umor size, (N)ode involvement, and distant (M)etastasis.10 Stage at initial diagnosis is an important predictive factor in survival. The National Comprehensive Cancer Network bases treatment recommendations on this staging classification.2 Physical examination and radiographic imaging, such as computed tomography, magnetic resonance imaging (MRI), and positron emission tomography (PET) are commonly used for accurate preoperative staging and treatment planning. Surgical Resection The most common treatment for both early stage and locally advanced tumors of the oral cavity remains surgery, selectively with the addition of radiotherapy.2 Challenges arise in the surgical management of these patients, especially those with advanced stage disease. These challenges include those related to surgical reconstruction and cancer control. Surgical resection is the most common primary treatment of malignant tongue lesions found in the anterior portion of the tongue. 2 A partial glossectomy (partial removal of the tongue) with or without unilateral or bilateral selective neck dissection is indicated for most tumors that are limited to the anterior two thirds of the tongue.2
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Resection of oral carcinoma typically includes a visible 1 to 2 cm margin of tumor-free tissue around the lesion to ensure complete resection.11 Tumor-free margins may be difficult to establish microscopically as current histopathologic methods are limited. The use of molecular markers may refine current methods.12 The author’s experience has shown that most small- and medium-sized tumors (T1 and T2) can be resected and closed primarily without the need for complex reconstruction. In most cases, there is a good functional result with limited speech and swallowing dysfunction. Previous radiation therapy or the presence of a tracheotomy can limit functional results.13 Functional results can also depend on the skill of the surgeon. Close follow-up is needed to monitor the area for local or distant recurrence. Resection of locally advanced lesions (larger T2, T3, and T4 lesions) can result in a large surgical defect. Locally advanced lesions in the oral cavity may also invade the adjacent mandible, which requires resection of the affected area of bone. Advanced T4 lesions of the tongue that have invaded neurovascular structures, the deep tongue musculature, or that involve both sides of the tongue may result in massive surgical defects.14 Resection of large tumors is associated with poorer functional outcome because of large surgical defects. Reconstruction of these surgical defects exemplifies the surgical challenges. A temporary tracheotomy is usually preformed to secure the airway. A nasogastric feeding tube or gastrostomy tube may be required during the postoperative period to ensure adequate nutritional intake. Reconstructive Options Many reconstructive options are available and are tailored to the individual patient based on the size, location, and tissue type of the surgical defect. Reconstructive options include split thickness skin grafts, pedicled myocutaneous flaps, and recently, the use of microvascular free tissue transfer.15 A split thickness skin graft can be used to reconstruct a small-to-moderate sized soft-tissue defect including the buccal mucosa, gingiva, and floor of the mouth.15 Large soft-tissue defects and defects into the neck and/or overlying skin will require complex reconstruction. A pedicled pectoralis major myocutaneous flap may be used. This type of graft maintains it blood flow from its original site. Radial forearm microvascular free tissue
transfer or other similar fasciocutaneous flaps are commonly performed as well. These flaps tend to be less bulky and more versatile than the pectoralis major flap, with better cosmetic and functional outcomes. However, this type of reconstruction is technically challenging and timeconsuming, as blood supply to the flap requires microvascular anastomosis to vessels in the area.15 Resection of oral carcinoma, which includes a full-thickness resection of a segment of mandible, is best reconstructed with a microvascular free tissue transfer that includes vascularized bone. The fibula, the long thin outer bone of the lower leg, is commonly used to reconstruct segmental defects of a section of the mandible. This type of microvascular free tissue transfer includes bone, muscle, and skin. It can be used in these cases to reconstruct both the bone and soft tissue defects. This helps to maintain dental occlusion and provides well-vascularized bone for osteointegrated dental implants.16 Titanium reconstruction plates are used to secure the sculptured fibula to the remaining mandible, which holds the tissue flap rigidly in place. The morbidity in this type of reconstruction is generally low; two teams can work simultaneously as the fibula is located far from the head and neck region.17 However, this type of reconstruction is timeconsuming and technically challenging. It also requires the patient to have good arterial blood flow to the lower leg. The iliac crest and scapula are other areas of the body where this type of free flap can be harvested, although these procedures are less commonly performed.15 Oral squamous cell carcinoma commonly metastasizes to cervical lymph nodes in the neck. Management of the neck is concurrent with treatment of the oral cancerous lesion.14 Controversy exists regarding management of the neck for early stage lesions in the oral cavity. The risk for metastases to the cervical lymph nodes increases in oral cavity tumors with tumor size and thickness.14 Frequently, patients with early stage disease (T1-2, N0) with no clinically evident lymph node metastases will undergo an ipsilateral selective neck dissection (removal of lymph nodes from the areas of the neck at the highest risk of metastatic tumor) given an estimated 20% to 30% chance of occult lymph node metastases.14 This may help prevent later recurrence of tumor in the cervical lymph nodes requiring additional surgery; however, an overall
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survival benefit has not been proven.14 Patients found to have lymph node metastases at initial presentation should undergo a neck dissection at the time of resection of the primary lesion.2 Postoperative Nursing Care Patients are placed in a postoperative recovery unit until they are stabilized from the withdrawal of anesthesia and mechanical ventilation. Once stabilized they can be transferred to a step down unit, with skilled nursing care, without the need for an intensive care environment. Nursing ratios range from one to two patients per nurse.18 Diligent postoperative monitoring is of particular importance in patients who require a microvascular free tissue reconstruction. Ensuring flap viability is important to secure a successful outcome because the tissue is entirely dependent on the anastomosed artery and vein for inflow and egress of blood.19 Inadequate arterial inflow or venous congestion from inadequate venous drainage or venous thrombosis can lead to flap failure if not recognized immediately. However, prompt recognition of a compromised flap allows for surgical repair before irreversible damage occurs to the flap tissue. Spiegel and Polat19 reported a 6.8% return rate of patients to the operating room to address flap complications. Several techniques have been used to monitor blood flow in microvascular free flaps. Arterial flow can be monitored by handheld Doppler ultrasound. Capillary refill in 1 to 2 seconds is also known as a reliable indicator of arterial flow. However, venous congestion is the most common cause for flap failure and can be more difficult to Instantaneous capillary refill recognize.19 (swelling and bluish discoloration of the flap) can be signs of venous congestion. The nurse should assess capillary refill and color of the flap at least every 1 to 2 hours in the immediate postoperative period.19 This can be challenging in the oral cavity where the flap skin may be difficult to visualize. A change in color or refill characteristics warrants immediate intervention, which may include returning the patient to the operating room to revise the microvascular anastomosis and remove any blood clots obstructing blood flow. When venous congestion cannot be corrected surgically or there is a delay in bringing the patient to the operating room, initiating medicinal leech therapy can help ensure survival of the flap.20 Patients are often placed on anticoagulants postoperatively,
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such as aspirin and intravenous dextran, and will need to be monitored for excessive bleeding.19 Monitoring the output and consistency from drains placed in the surgical areas of the neck is a critical factor in patient care. An increase output of an odorless milky consistency, especially after oral intake has started, may indicate a chyle fistula. Chyle is composed of lymphatic fluids and fat globules that line the intestine. The production of chyle is increased in relation to oral intake of fats and triglycerides. Although rare, management of this type of fistula may be conservative by limiting dietary fats and medium chain triglycerides. If managing diet is unsuccessful, surgical repair is indicated.21 A cloudy odorous type of output may indicate a salivary fistula. This type of fistula has an extremely variable incidence, ranging from 5% to 65%.22 Drainage should be sent for amylase analysis if a salivary fistula is suspected.23 Conservative management includes adequate continued drainage, neck compression, antibiotics, and frequent dressing changes.22 Surgical repair may be indicated if conservative measures prove unsuccessful. Chemotherapy/Radiation Therapy Primary treatment with combined chemotherapy and radiation therapy or radiation therapy alone is used for locally advanced tumors that are unresectable because of large tumor size larger 8 cm, carotid artery encasement, and/or pre-vertebral fascia involvement.24,25 Combined chemotherapy and radiation therapy may also be considered when surgical resection would result in overwhelming functional and cosmetic defects or in patients who are not candidates for surgery because of underlying co-morbid medical conditions. The addition of chemotherapy to radiation therapy after surgery has been shown to decrease recurrence and improve survival in selected cases with poor prognostic features. These poor prognostic features include large tumor size, close or positive surgical margins, histopathologic features (such as perineural invasion or vascular invasion), advanced nodal disease, and extra-capsular extension of tumor involving the cervical lymph nodes of the neck.24 Salvage Surgery Patients with residual or recurrent cancer after chemotherapy and radiation therapy may be
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candidates for salvage surgery. However, healing is often delayed by the effects of chemoradiation, and surgery is technically more difficult. This leads to a higher risk of wound breakdown and salivary fistula formation because of compromised tissue vascularity, tissue fibrosis, compromised nutritional status, poor blood supply, and impaired lymphatic drainage caused by prior treatment.26 Salvage surgery is viewed as a last chance for cure. This can be a difficult concept for the patient and family to comprehend, especially when chance for cure is minimal. Locoregional control and survival rates for the patient undergoing salvage surgery after chemoradiation therapy are not encouraging.27 One non-randomized retrospective study looked at 204 patients that received chemoradiation, 38 recurred and underwent salvage surgery. Overall survival was reported at 60% for 12 months and 27% at 2 years. Locoregional control was 42% at 2 years; surgical morbidity was reported at 24%. Lower survival rates were seen with advanced (N3) neck disease.27 Gokhale and Lavertu26 reviewed several studies on complications and outcomes in this select group of patients and found similar findings in complication rates, especially when salvage surgery was performed at the primary site of disease. Nursing Implications. Patients who have had radiation therapy or combined chemotherapy/ radiation therapy before salvage surgery pose a unique set of postoperative concerns. Surgical morbidities include wound breakdowns in the irradiated field of the neck causing tissue necrosis, infection, bleeding, and salivary fistulas.27 This can result in exposure of the carotid artery, which requires protection with vascularized tissue to prevent rupture. As tissue continues to breakdown in the surgical area, exposure of reconstructive hardware and bone can increase the risk for infection and further wound breakdown. The use of drains, antibiotics, oral hygiene, packing the wound, and wound vacuum dressings can help decrease the risk of infection and promote formation of granulation tissue to support healing.28 During an extended postoperative recovery period the patient may have difficulty communicating, be tracheostomy dependent (for secretion and airway management), be reliant on enteral feeding, and have extreme facial disfigurement. Withdrawal from alcohol during this period can also complicate and prolong recovery. There is
a significant need for a multidisciplinary team approach to assist the patient and their support systems with adjustment to these issues.26 In patients that have undergone extensive head and neck surgery, the need for a tracheostomy is a critical initial step in securing the airway. Postoperative factors to be considered before removing a tracheostomy (decannulation) are the patients’ level of consciousness, effectiveness of cough to clear secretions, and resolution of any postoperative swelling in the upper aerodigestive tract.29 A trial period of capping the tracheotomy tube can give some insight to readiness for decannulation. A speech pathologist can assist with communication needs and determine the patient’s ability to tolerate oral intake safely and avoid aspiration. Consultation with a registered dietician can provide information on appropriate caloric intake to promote healing.30
LARYNGEAL CARCINOMA Laryngeal carcinoma is the second most common form of head and neck cancer. It accounted for 12,250 new cases in the United States in 2008. There were 3,670 associated deaths.31 The age adjusted incidence rate was 3.5 per 100,000 per year. Median age at diagnosis was 65 years. It is approximately six times more common in men.32 Risk factors for development of this form of cancer include tobacco and/or alcohol abuse. Other factors include exposure to wood dust, nitrogen mustard, asbestos, and nickel.33 The larynx is a complex neuromuscular organ that has three main functions: airway protection, phonation, and respiration. The larynx acts like a sphincter, providing airway protection during swallowing. To avoid aspiration, the true vocal cords, false cords, and epiglottis/aryepiglottic folds closed and the larynx is raised during swallowing. The true vocal cords contact each other to produce sound when air passes between them. Phonation occurs when this sound is converted to recognizable words by muscle contractions/relaxation in the oral cavity and tongue.34 The larynx is divided into the supraglottic, glottic, and subglottic areas. Tumors arising in the supraglottic area tend to cause dysphagia that can result in aspiration. Patients with supraglottic tumors often remain asymptomatic for some time and tend to present with advanced disease.35 Tumors in the glottic area are more common and localized.
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Patients with tumors in this area tend to present with voice changes or hoarseness. Lesions in this area can easily compromise the airway. Increased shortness of breath or difficulty breathing makes a tracheotomy necessary to improve breathing. Patients with glottic lesions often present earlier because of symptoms of hoarseness or difficulty breathing. Lesions presenting in the subglottic area are rare and account for about 1% to 8% of all laryngeal cancers. They are usually extensions of lesions arising in the supraglottic or glottic area.36 Treatment of laryngeal cancer is based on tumor stage at initial presentation.2 The majority of laryngeal cancers are squamous cell carcinoma. The goal of laryngeal cancer management is to maximize cancer control while preserving functions of airway protection, swallowing, and voice production. Early Stage Laryngeal Cancer (T1/T2) Early stage laryngeal cancer is generally treated with either radiation therapy or surgery alone.2 Radiation therapy and surgery seem to have similar survival rates for treatment of early glottic and supraglottic cancer; however, there are no randomized controlled trials that compare conservative surgery with radiation therapy in this patient population.37 Radiation therapy for glottic cancer is usually confined to a small field because the risk of lymph node metastases is very low. Radiation for supraglottic cancer incorporates a larger field that includes the lateral neck on both sides due to a high risk of bilateral lymph node metastases.37 Surgery for early stage laryngeal cancer generally does not require complete removal of the larynx. Surgical options for early glottic carcinoma include endoscopic excision of the lesion.2 This can be accomplished by cordectomy (removal of the vocal cord) if the lesion does not extend to the anterior commissure or arytenoid cartilage. Open partial laryngectomy, sometimes referred to as a vertical hemilaryngectomy, removes approximately half of the larynx and is one of several partial laryngectomy procedures. Tumor extension to certain areas, such as the posterior commissure, arytenoid cartilage, and thyroid cartilage, are considered contraindications to this type of surgery.34 Surgical management of early supraglottic cancer is generally performed by open supraglottic laryngectomy, which removes the upper part of the larynx but preserves the true vocal cords and
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arytenoid cartilages. Supraglottic cancers have a high incidence of lymph node metastases; therefore, neck dissection and postoperative radiation therapy are often used.35 Cancer control rates are similar to that of radiation therapy alone. The decision to perform primary radiation therapy or surgery is based on anticipated functional outcome, because cancer control rates are similar.34 Superficial cancers of the glottic larynx limited to one vocal cord may be easily removed endoscopically with excellent voice outcome.38 More extensive lesions require resection of more tissue, and may be associated with poorer voice quality than radiation therapy. Open partial laryngectomy procedures are often associated with a significant impact on voice quality and swallowing, especially with vertical partial laryngectomy and the supraglottic laryngectomy.34 These procedures are less commonly performed today for these reasons. Newer techniques for surgical resection of early stage glottic or supraglottic laryngeal cancers along with selective neck dissection may change the treatment choice for some patients. Transoral endoscopic procedures, so-called minimal access surgery, have been used in recent years with excellent reported oncologic and functional outcomes in highly selected patients.38 These techniques include transoral CO2 laser resection and, more recently, transoral robotic-assisted surgery. Small, well-circumscribed lesions in the supraglottis and glottic larynx, as well as selected larger tumors, can be resected using the laser.39 Reported benefits include excellent functional outcome and avoidance of tracheostomy in most cases. Swallowing can be affected by the extent of laser resection and aspiration can occur postoperatively.40 Roh et al40 reported 3-year locoregional control, disease-free survival, and overall survival as 81%, 71%, and 79%, respectively. However, laser surgery is time-consuming, technically challenging, and resource intensive. It is currently performed only in specialized centers. Advanced Laryngeal Cancer (T3/T4) Management of advanced stage laryngeal cancers typically requires multimodality treatment. The previously accepted treatment for advanced laryngeal cancer was total laryngectomy with or without postoperative radiation therapy. However, in recent years, nonsurgical management with combined chemotherapy and radiation therapy, also known as ‘‘organ preservation,’’ is more common.2 When
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total laryngectomy is required, it involves a surgical procedure that removes the entire larynx. This procedure separates the upper aerodigestive tract from the trachea. Air no longer passes into the mouth or nose. The patient is left with a permanent tracheal stoma in the neck for breathing. This results in a loss of smell, which decreases the sense of taste. Patients no longer can sniff, sneeze, or blow their nose. They also lose their ability to phonate. Indications for this surgical procedure are reserved for locally advanced laryngeal lesions in patients ineligible for chemotherapy and radiation and for recurrence following primary treatment with chemoradiation. It is not indicated for patients with distant metastatic disease or with severe co-morbid medical conditions.41 The patient who has a total laryngectomy and permanent tracheal stoma will encounter numerous issues (ie, communication challenges, changes in activities of daily living [showering/bathing routines], potential oral and airway dryness, concerns about dust and environmental irritants, and changes to social and outdoor recreational activities [eg, swimming, boating]). Voice rehabilitation can be accomplished in several ways, including use of an electrolarynx, use of tracheo-esophageal prosthesis, or esophageal speech.35 The Cooperative Studies Program of the Veterans Affairs Laryngeal Cancer Study Groups’ landmark study reported on the ability to preserve the larynx in patients with advanced laryngeal cancer.42 This prospective randomized study compared patients treated with surgery with those treated with sequential chemotherapy and radiation, with surgery reserved for non-responders to chemotherapy. They found that the 2-year survival rate was 68% for both groups. At 3 years, 40% of patients who received chemoradiation remained disease-free with an intact larynx. Although the chemotherapy and radiation protocols have evolved since the time of this study, the finding established the trend toward organ preservation in the management of advanced laryngeal cancer. The aim of this type of treatment is to avoid a permanent tracheal stoma and maintain the normal function of the larynx while still controlling the cancer. Chemoradiation is now accepted as a treatment alternative for patients who require a total laryngectomy.33 Its use has been extended to patients with less extensive tumors who may be candidates for partial laryngectomy. However, chemoradiation therapy is associated with significant side
effects, including acute mucositis, long-term xerostomia, and dysphasia. Management with chemoradiation requires careful monitoring. Salvage surgery will be indicated if there is residual or recurrent tumor. Salvage surgery often requires total laryngectomy, even in patients who may have been candidates for partial laryngectomy before treatment. The functional outcome for patients treated with chemoradiation is often excellent. One study found better long-term quality-of-life scores associated with physical functioning and social interactions in patients treated with chemoradiation as compared with those treated with total laryngectomy with voice prosthesis.43 They reported fewer problems with pain, speech, breathing, and sleep disturbances; however, some patients had severe swallowing difficulty and required long-term gastrostomy tubes and some patients with airway obstruction required long-term tracheostomy. In these cases, the larynx may have been preserved, but function was not. The role of chemoradiation in patients with extensive local tumor, especially with thyroid cartilage invasion, has not been clearly established.14 It appears that the likelihood of success of chemoradiation is decreased in such cases, although it may also be decreased with primary surgery as well. Unfortunately, no direct comparative data yet exist in this subgroup of patients. The use of robotic-assisted surgery is investigational, but may play an important role in enhancing surgical accuracy and performance. Robotics in laryngeal surgery may prove to overcome some of the shortcomings of endoscopic laser surgery, such as limitation of visual fields, increased degree of instrumentation freedom, and elimination of tremor.44 The use of robotics in head and neck surgery, although feasible, may be inhibited by its high cost and need for specialized training. Further research is needed and must include prospective randomized trials to determine efficacy and safety. Benefits to patients and health care systems need to be evaluated to justify the expense.45 Nursing Implications Immediate postoperative care focuses on maintaining a patent airway, nutrition, fluid and electrolyte balance, drain output, and communication. Suctioning and frequent changes of the tracheotomy/laryngectomy tube’s inner cannula help to
SURGICAL MANAGEMENT OF HEAD & NECK CARCINOMA
FIGURE 1. Classifications of Lymph Node Groups by Level and Associated Primary Risk Sites49 Level I Submental – Tumors originating from the floor of mouth, anterior tongue, mandibular alveolar ridge, and lower lip Submandibular - Tumors originating from the oral cavity, nasal cavity, midface soft tissue, and submandibular gland Level II Upper Jugular Area - Tumors originating from the nasopharynx, hypopharynx, oropharynx, larynx, oral cavity nasal cavity, and parotid gland II (a): Upper one-half of the superior jugular area II (b): Lower one-half of the upper jugular area The structure separating II (a) from II (b) is the spinal accessory nerve, the lower boarder of II (a) Level III Middle Jugular Area - Tumors originating from the nasopharynx, hypopharynx, oropharynx, larynx and oral cavity Level IV Lower Jugular Area – Tumors arising from the hypopharynx, upper esophagus and larynx Level V Posterior Triangle – Tumors arising from the nasopharynx and oropharynx V (a) Includes lymphatics that follow the spinal accessory nerve V (b) Includes lymphatics that lie along the transverse cervical artery Level VI Anterior Compartment of the Neck – Tumors arising from the thyroid gland, cervical esophagus, glottic and subglottic areas of the larynx and pyriform sinuses
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keep the airway free from developing a mucous plug. A temporary nasogastric feeding tube is usually placed at the time of surgery to allow for nutritional intake and for the pharynx and esophagus to heal. Some patients require free flaps such as laryngopharyngectomy and then corresponding care is required. A writing pad with pen or pencil can provide a simple way for patients to communicate, but this can be frustrating for both the patient and staff, especially if patients are illiterate or English is not their first language. A communication board, picture board, or cards can provide a less frustrating way to communicate immediate needs. Patient education will include stomal cleaning and secretion management. Communication rehabilitation for patients having had a total laryngectomy will focus on several options. A tracheo-esophageal puncture can be preformed for placement of a valve.46 The surgical procedure creates a tract between the posterior wall of the trachea and the anterior wall of the esophagus within the tracheal stoma. A one-way valve is placed into the created tract. Air from the trachea is pushed through the valve and into the esophagus and pharynx when the patient covers the stoma and attempts to exhale. The air vibrates the upper pharynx and is modulated by the tongue and pharynx, thereby creating speech. This procedure can be performed at the time of laryngectomy or at a second surgery. Although the quality of the speech is monotone, it is easily understood even over the telephone. Cleaning of the speech prosthesis and periodic changes of the prosthesis are required. A similar technique for communication is esophageal speech. The patient swallows air and is taught to control the release of that air, almost like a burp, to vibrate tissues in the pharynx causing sound. This technique can be difficult for most patients to perform without the assistance of a speech language pathologist. A common method for communication after laryngectomy is the use of an electrolarynx, a mechanical device that produces vibrations and sound. The device is placed in an area on the neck where the vibrations and sound travels into the oral cavity. The vibrations and sound are converted to words by the muscles in the pharynx and tongue. Oral adapters are available for patients that have severe fibrosis of the soft tissues in the neck caused by surgical scarring and radiation therapy. The speech quality is mechanical sounding, but is easy for most patients to learn and does not require a surgical
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procedure or upkeep. The electrolarynx can be permanent or used temporarily, until a tracheoesophageal puncture is performed.46
METASTATIC NECK DISEASE One of the first individuals to describe the lymphatic drainage in the head and neck was Dr. Henri Rouviere, who set the groundwork for future work in this area.35 Robbins et al47,48 have identified levels of lymphatics in the head and neck and identified the primary sites associated with risk for metastatic disease. Figure 1 illustrates these levels and associated primary tumor sites. Lymphatic metastases occur at predictable levels of the neck depending on the site of the primary tumor. Lymph nodes that are involved with tumor may be contained within the lymph node or include extra capsular extension into nearby nerves, salivary glands, muscles, and blood vessels. The lymphatics and various other structures must be treated to avoid recurrence and spread of disease. The removal of the cervical lymph nodes involves a neck dissection or cervical lymphadenectomy. The indication for and the extent of a neck dissection, concurrent with primary tumor resection, is determined by the size and site of the primary tumor, presence and extent of obvious metastatic neck disease, or estimated risk of metastases to the neck when there is no obvious metastasis.47,49 A neck dissection may also be performed after chemoradiation when there is suspected residual cancer involving lymph nodes present on MRI or PET scan or in patients with advanced neck disease at presentation. Cure rates drop by almost 50% in patients with metastatic neck disease compared with patients with similar sized primary tumors without metastatic neck disease.14 Surgical procedures used to perform the neck dissection are: the radical neck dissection, modified radical neck dissection, extended radical neck dissection, and the selective neck dissection. See Table 1 for a description of these procedures. Radical neck dissection can be combined with resection of the primary site or following primary radiation therapy. It is indicated when tumor is extensive or in the presence of extra capsular extension.49 Cosmetic alterations in the contour of the neck occur as a result of this procedure. Limited range of motion of the shoulder resulting from removal of the spinal accessory nerve can occur. This can lead to chronic pain, shoulder
droop, and atrophy of the trapezius muscle along with shoulder fixation. An extended radical neck dissection is reserved for extensive disease that has invaded additional lymphatic and nonlymphatic structures not already included in the radical neck dissection.50 This may include skin, carotid artery, vagus, hypoglossal nerve, and additional lymphatic groups such as mediastinal, parapharyngeal, or paratracheal. Cosmetic and functional defects are dependent on what is resected at the time of surgery. Speech and swallowing dysfunctions can occur when the vagus and/or hypoglossal nerves are sacrificed.50 The modified radical neck dissection is indicated for a patient with metastatic disease in the neck that does not involve or adhere to this nonlymphatic structure.49 Problems related to trapezius muscle weakness (eg, raising the arm above the shoulder) can be avoided or decreased in many patients by preserving this nerve. The selective neck dissection is commonly used for patients without obvious cervical lymph node metastasis, and is often referred to as an elective neck dissection. Some advocate its use in patients with known lymph node metastases when there is a limited degree of neck disease.49 Previous terminology described such procedures as suprahyoid neck dissection, supraomohyoid neck dissection, lateral neck dissection, anterior neck dissection, and posterolateral neck dissection. A uniform terminology was suggested by The American Head and Neck Society (AHNS) and the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Committee for Head and
TABLE 1. Types of Neck Dissection
Radical neck dissection
Modified radical neck dissection
Selective neck dissection
Removes all lymphatics from levels I through V, the sternocleidomastoid muscle, the jugular vein, submandibular gland, and spinal accessory nerve Removal of all lymphatics from levels I, through V with preservation of one or more non-lymphatic structures (eg, spinal accessory nerve, jugular vein or sub-mandibular gland) Removes lymph nodes from selected levels only, rather than all V levels. The levels removed depends on primary cancer site and lymph nodes at greatest risk for metastases
SURGICAL MANAGEMENT OF HEAD & NECK CARCINOMA
Neck Surgery and Oncology. The 2008 Consensus Statement included recommendations that the term ‘‘selective neck dissection’’ be used with specific notation to the levels and/or sublevels of lymphatics removed.48 For example, a practitioner planning a selective neck dissection for a T2 tongue carcinoma would include levels I through IV. New recommendations suggest that it be reported as a selective neck dissection, sublevels Ib, IIa, III, and IV, rather than an extended supraomohyoid neck dissection. Nursing Implications Patients need to be informed of the potential complications that may occur after neck dissections. Complications include bleeding, lymphatic leak, nerve injury, wound infection, chyle fistula,
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skin flap necrosis, and carotid artery rupture. Cosmetic deformity, shoulder pain, and dysfunction are of major concern. Physical, psychosocial, speech, and swallowing rehabilitation are necessary components of care, which are met through a multidisciplinary approach.
CONCLUSION Surgical management of tumors in the head and neck is complex and challenging. It is influenced by tumor size, location, previous treatment, and histopathology. Technologic advances have led to better preoperative planning, improved intraoperative interventions, decreased postoperative functional defects, and extended survival in select cases.
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