Surgical palliation of head and neck cancer

2. SURGICAL PALLIATION OF H E A D A N D

NECK C A N C E R Lucio Fortunato, MD, and J o h n A. Ridge, MD, PhD

INTRODUCTION

Approximately 45,000 new squamous cell cancers of the uppe r aerodigestive tract are diagnosed each year in the United States. ~ Cigarette smoking is the most important causative agent. It is esti- ma ted that 75% of these cancers could be prevented if tobacco use ended.Z

Approximately one third of patients are first seen with stage I or II tumors (T1-T2, NO, M0). Most of them will be cured with either surgery or radiation. The choice depends largely o n the pr imary tumor site, the availability of t reatment teams, and the patient 's preference. The chance that a patient will succumb to stage I or II squamous cancer of the head and neck is similar to the risk of dying from a second primary tumor of the uppe r aerodigestive tract, a' 4

Unfortunately, the majority of head and neck tumors are diagnosed at more advanced stages, of which only about 30% are curedfi The majority die with recurrent disease, though some are never rendered even temporarily cancer free. However, in spite of advanced presentation, most advanced head and neck tumors are potentially curable. Patients may be candidates for surgery, radiotherapy, or combined treatment with curative intent. Morbidity of extensive resections and postoperat ive function play an important role in select- ing therapy. Often a combinat ion of surgery with radiation will be necessary to achieve local control and survival. Preoperative radiation, postoperative radiation, and radical radiation followed by surgery (for salvage) seem to achieve similar results in this setting, 6 although morbidity is increased if surgery follows radiation.

~Unresectability ~ is suggested by invasion of the skull base, prever- tebral fascia, or paraspinal musculature . This status is usually as- signed preoperatively, on clinical grounds or through diagnostic im- aging. Fixed lymphadenopa thy can often be rendered resectable with radiation therapy. Large tumors of the tongue base, pharyngeal wall, or both, which necessi tate total g lossectomy or pharyngolaryn- gectomy, may be treated as "unresectable" because of concerns regarding quality of life after operation. Some inoperable cancers are still curable. About 20% of patients whose advanced cancers are

Curr Probl Cancer, May/June 1995 153

t reated with radiation alone will survive. 7 Mediastinal lymphadenop- a thy or distant nonpu lmonary metastases prec lude cure.

All too many head and neck cancer patients, even with appropriate and aggressive treatment, will experience tumor recurrence. Cases amenable to surgical salvage with frequent cure include those with cervical metastases in the unopera ted neck and those with local recurrence after radiation (particularly for tumors of the larynx).S Other local and regional recurrences may be susceptible to surgical attack, bu t most individuals will die from symptoms referable to local or regional tumor. The median survival with unresectable recurrent squamous cancer of the head and neck is about 6 months, 9 even with the best current chemotherapy.

TREATMENT SEQUELAE

To ~palliate" disease is to conceal its effects, thus restoring dignity and comfort. Occasionally, w h e n patients are free of tumor, physicians may need to palliate symptoms or functional deficits resulting from treatment.

Osteoradionecrosis is primarily due to radiation fibrosis of small b lood vessels and hypovascularity. 1~ 11 Radiat ion-induced thrombo- sis of the inferior alveolar artery has also been d o c u m e n t e d in these cases and implicated as an etiologic factor. 12 The most vulnerable part of the mandible is the buccal cortex of the premolar, molar, and retromolar regions. Osteoradionecrosis occurs in approximately 10% of patients after radiation. 13 Such risk is dose related. ~4-16 Proper soft-tissue reconstruction, adequate osteosynthesis after a mandibu- lotomy, avoiding dental extractions after radiation, and meticulous postoperat ive oral hygiene are very important to prevent this complication. ~'~8 All patients planning to receive radiation therapy should have a thorough dental evaluation before treatment. Prophy- lactic tooth extraction should be considered if, in the dentist 's judg- ment, the teeth will not remain for the rest of the patient 's life. When the diagnosis of osteoradionecrosis is entertained, a panorex is usually required to evaluate the extent of bone involvement. Treatment with hyperbaric oxygen should be considered. TM Debridement of the exposed bone and primary mucosal closure may help rare patients with chronic but nonprogressive disease. Mandibular resection is reserved for patients with progressive disease, intractable pain or tris- mus, and severe infection. Bone-bearing tissue transfer will restore mandible continuity.

Orocutaneous or pharyngocutaneous fistulae represent consider- able morbidi ty for the patient. Fistulae are c o m m o n after laryngectomy. z~ Large cancers, complex resections, preoperative radiation, malnutrition, and comorbid condit ions (such as diabetes or arterio-

154 Curr Probl Cancer, May/June 1995

sclerosis) are considered potential risk factors. Once the fistula has developed, the w o u n d should be opened or the tract drained to direct saliva away from the carotid artery. Necrotic tissue should be debrided, local w o u n d care instituted, and systemic antibiotics ad- ministered. Most fistulae will r e spond to conservative treatment. Pa- tients who received radiation may need surgical intervention to close the defect with a myocu taneous flap, protecting the carotid artery from infection and rupture.

Although the larynx has developed primarily to protect the airway, 21 patients after laryngectomy often enjoy speech. Esophageal speech is successful for 30% to 60% of such patients. 22 Some will be able to speak in public with little limitation. Unfortunately, many patients do not do well with this technique and employ an electric vi- brating device to communicate . Surgeons have created communica- tions be tween the trachea and the pharynx to direct air through the mou th and provide speech. 2~' 24

ADVANCED CANCER

In practice, palliation is most often offered to patients with unresectable, recurrent, or persistent cancer. Without treatment, most such patients suffer cont inuous pain. Their tumors will ulcerate, bleed, and be malodorous, limiting social contacts. Cancer cachexia weakens patients, and local recurrence will often prevent mou th opening, limiting nutrition. Problems with aspiration will impair eat- ing and breathing. These frightening eventualities are m u c h feared and provide the impetus for aggressive efforts to control head and neck tumors.

The medical communi ty has not aggressively addressed the problems of these patients with recurrence. The dismal ou tcome and the frustration that accompanies t reatment of an incurable and unpleas- ant condit ion lead to withdrawal from patients and their referral for "terminal care."

How "active" palliation should be is controversial. Allowing patients with fatal disease to die of dehydrat ion has been advocated. 2~ However, most doctors pursue some form of treatment. Whether palliative treatment, providing aggressive supportive care, can improve survival (in addit ion to quality of life), is not known with re- spect to head and neck cancer.

Patients with unresectable tumors of the head and neck are usually treated with external beam radiation. For advanced tumors (T3- T4, N2-N3), the initial complete response rate is be tween 33% and 63%.26 Only 15% are free of cancer at 5 years. 2z Often patients with recurrent t umor cannot receive radical radiotherapy because of prior radiation treatment. They may receive radiation at r educed


doses or with concurrent chemotherapy. Palliative radiation may al- leviate symptoms, difficulties with speech and swallowing, bleeding, or discharge from exophytic tumors. Dosage schedules d e p e n d on the radiation tolerance of the structures in the ports. Because laryngeal edema may be significant at doses exceeding 225 cGy per frac- tion, or total doses greater than 60 Gy, hypofract ionated therapy is only occasionally applied to palliate head and neck patients. Those with advanced tumors or metastatic disease may be treated with an abbreviated schedule. Symptomatic recurrent disease may also be palliated with brachytherapy 2a' 29 or further external beam radiation combined with hyperthermia, a~

Induct ion chemotherapy, concurrent chemoradiation, or adjuvant chemotherapy do not consistently improve local control. 7,al'a2 Metastatic or otherwise untreatable disease is the single universally accepted indication for administration of chemotherapy in the management of head and neck cancer. 3a The main goal is palliation of symptoms with improvement of function. Current regimens do not improve survival (in comparison to withholding chemotherapy). Although in the induct ion setting response rates as high as 70% to 90% have been reported, with recurrent or metastat ic disease, the response to single-agent chemotherapy is approximately 30%, and the median survival is 5 to 7 months, a4 Combina- tion therapy has increased response rates but not enhanced survival, aa Aggressive regimens are associated with substantial morbidity, so quality of life should concern physicians. It has not been s tudied systematically.

For unresectable cancers, there is no evidence that non-curative ~debulking" improves survival. However, techniques have been developed in an effort to palliate these patients. All are investigational.

Cryotherapy destroys tumors by coagulation necrosis, a5 This technique has been applied for multiple, superficial lesions of the oral cavity, in elderly debilitated patients, and for leukoplakia, a~' a7 Efforts to relieve symptoms and improve function have been described, aa-4~ Such palliation for tumors of the oropharynx has been characterized as inadequate, aa With photodynamic therapy, a light-activated drug destroys tumor. Hematoporphyr ins are concentra ted in tissues 48 to 72 hours after intravenous injection. Isolated reports for palliative t reatment of head and neck cancer are available. 41'42 Most tumors respond temporarily to treatment, but the benefit is uncertain. Bulky tumors and neck metastases benefit least. 42 Other potential applications of this therapy include delineation of tumor margins and treat- men t of stomal recurrences. 4a

Laser ablation has been employed as a palliative modali ty for unresectable head and neck tumors. 44 Several reports have addressed the value of this technique to relieve malignant dysphagia, maintain airway patency, and improve quality of life in patients with esopha-


geal tumors. 45-49 Improved survival after endoscopic t reatment has been reported. 46

Squamous cell carcinoma of the head and neck will remain local- ized above the clavicle in more than two thirds of the cases. The risk of distant metastases correlates with the nodal status and varies from 10% with NO or N1 tumors to 30% with N2-N3 tumors. 5~ More than half of deaths result from compromise of local structures. 5z Pain management , nutrition, control of the airway, and control of bleeding are primary objectives in ameliorating symptoms.

PAIN MANAGEMENT

Pain is an alarming symptom for the patient and the doctor. It often portends poor prognosis and has a deep psychological and functional impact on patients and their families. Until recently, the importance of cancer pain management was not fully recognized. Pain control is the most common problem in palliative care. In re- cent years, it has become a clinical specialty, involving a multidisci- plinary approach. 5a-57 Pain in cancer patients can be controlled most of the time. 5a-61 However, unrelieved pain is common because of under t rea tment and fear of addiction. G2

Unfortunately, head and neck cancers have easy access to cranial nerves, the cervical plexus, sensory ganglia, and sympathetic trunks. Squamous cell carcinomas ulcerate and invade surrounding structures with infammat ion . The lingual nerve, mandibular branch of the fifth nerve, and the glossopharyngeal nerve are those most com- monly responsible for chronic pain from head and neck cancer. 6a

Of patients with unresectable tumors of the head and neck, 85% have significant pain. 5z' 64 Pain is due to cancer in about 70% to 80% of these cases but may also occur as a result of surgery, radiation, chemotherapy (15%), or other nonneoplastic preexisting or concurrent problems .65, 66 Patients without pain eat better, sleep better, and are less isolated socially, even if they have a dismal prognosis. Spe- cialists in pain control can now offer a variety of approaches and in- dividualized treatment. Analgesics, sedatives, nonsteroidal anti-in- f lammatory drugs (NSAIDs), steroids, antidepressants, and anticon- vulsant drugs can be used alone or in combinations to achieve the best results. 62

Otherwise intractable pain may be treated by alcohol or phenol in- jections of sensory cranial nerves and the cervical plexus. 28 Trigemi- hal and multiple rhizotomies, peripheral neurolysis, central trac- totomy, stereotaxic thalamotomy, and leukotomy have also been employed when other approaches fail. 6a' 67-69 They should be reserved for patients whose life expectancy is measured in weeks, rather than days.


~ T I O N

Nutritional needs of patients with advanced malignancies have been recognized since Warren considered malnutrit ion a comorbid condit ion some 60 years ago. T~ About 40% of patients with head and neck tumors are malnour ished at presentation71' ~z Dysphagia and inability to maintain adequate oral intake are repor ted in at least one third of unselected cases, 5z and two thirds of patients with unresectable tumors develop these problems some time during the course of their disease. 64 Weight loss may be severe and rapid. Aggressive cancer t reatment may exacerbate this clinical picture, and the majority of patients receiving multimodali ty therapy have significant weight loss. 7~ For most tumors, adequate nutrition seems to improve tolerance to chemotherapy and radiation and to improve quality of life.~4-zs

Prognosis, morbidity of treatment, and risk for recurrence have been correlated with the nutritional status.74' rr, rs

Patients with head and neck tumors are good candidates for simple nutrition suppor t because they have a functioning gastroin- testinal tract. Nasogastric feeding is easy, but patient discomfort and cosmetic concerns have encouraged alternative techniques. Feeding je junos tomy needs a constant infusion to provide adequate nutrition wi thout causing diarrhea, so it is impractical for most outpa- tients. Long-term nutritional suppor t is best afforded by tube gastrostomy. Until 1980, this was p e d o r m e d during a laparotomy. Since then, pe reu taneous endoscopic gastrostomy (PEG) has become a popular procedure , s~ Although PEG avoids a laparotomy, the complicat ion rate is similar to that of the open procedure . Major morbidi ty of 5% to 32% is usually reported, sl-9~ but this may be as high as 80% in patients with advanced head and neck cancer. 9~ Preoperative antibiotics decrease the w o u n d infection rate and are recommended.S6, s9 Mortality from this procedure is not rare, s~-~' ~ probably reflecting the poor general health of patients with advanced head and neck tumors. Tumor implantation at gastrostomy sites has been repor ted w h e n the catheter was "pulled" past the tumor. 9z-94 No such patients have been salvaged even with surgical attack.

One retrospective comparison of different techniques in 75 patients with advanced head and neck tumors suggested that open gastrostomy has a lower complication rate than PEG, 9,~ but PEG is probably cheaper because it is usually under taken in a gastrointesti- nal suite, rather than in the operating room. 96' 95, 96 Tubes are readily p laced into the s tomach at laparoscopy, 97-~~ or unde r radiologic control,lOZ, lO3 with complication rates similar to those of PEG and open gastrostomy.

1 ~ Curt Probl Cancer, May/June 1995

AIRWAY

Respiratory failure is the most c o m m o n cause of death in patients with recurrent head and neck cancer. ~4 Some 20% of patients develop respiratory distress, and another 25%, pneumonia before death. 64 Air hunger is frightening for patients. Even patients emo- tionally averse to therapeutic interventions cannot tolerate airway obstruction. The need for a t racheotomy in patients with unresectable tumors of the neck, oral cavity, oropharynx, hypopharynx, and larynx should be recognized before an emergency ensues. Most patients are symptomatic for some time. Palliative radiation, a com- paratively minor uppe r airway infection, or anxiety may acutely exacerbate air hunger. However, signs of obstruct ion may be subtle. A gentle indirect laryngoscopy or an examination with a flexible in- s t rument may document edema, cord paralysis, or massive tumor. Prophylactic t racheotomy should be p lanned before initiating therapy ff there are concerns regarding potential airway complications. Even an elective t racheotomy in this setting should be re- garded as a formidable endeavor with risk of mortality. Recurrent cancer or prior surgery may distort anatomy. Endotracheal intuba- tion by the anesthesiologist may be difficult, al though it is almost al- ways possible. Tumor hemorrhage is to be feared, and manipulat ion may p roduce life-threatening edema. Instillation of local anesthetic into the airway or regional blocks may precipitate a crisis. The same problems at tend t racheotomy planned under local anesthesia. The surgeon should be in the operating room when airway manipulat ion begins. When preparing for an elective tracheotomy, all should be aware that need for immediate control of the airway may emerge suddenly.

Occasionally, patients have recurrent aspiration due to tumor involvement with the larynx, pharynx, or tongue base. A t racheotomy will not prevent such aspiration (and indeed may worsen the problem), but it should improve pulmonary toilet and result in adequate care. If laryngeal dysfunction alone prevents oral food intake, then laryngectomy should be entertained in patients without recurrence who have radionecrosis of the larynx. Most patients wou ld rather eat than talk.

C O N T R O L O F B L E E D I N G

More than 10% of deaths from head and neck cancer have been caused by hemorrhage, and 20% of recurrent cancers bleed. 64 This is usually treated without operation because it represents truly advanced disease.


Carotid "blow-out ~ is dramatic. Neck radiation is the most important risk factor. 1~176 E x p o s u r e of the carotid artery through skin flap necrosis, pharyngocutaneous fistula, and tumor invasion have been implicated. 1~176 109 With recognition of "sentinel bleeding," appropriate t reatment in selected patients may be instituted. Even seemingly trivial bleeding may herald carotid rupture. The patient prognosis must be determined. If reasonable suivival and quality of life are anticipated (as is common with postoperative carotid rupture), then ligation of the carotid artery may be performed urgently. In the presence of active bleeding, direct pressure should be applied to the site. The airway should be protec ted and efforts made to prevent aspiration. The patient should be sedated and fluid resuscita- tion initiated while an operation is organized. Death (32% to 77%) and permanent neurologic deficits (12% to 50%) after emergency carotid artery ligation are common. 11~ Occasionally, interventional ra- diologists can occlude the vessel proximally and distally, wi thout opening the neck. 11~ Stroke is u n c o m m o n if the blood pressure is normal w h e n the vessel is occluded. Treated patients should have tissue flap coverage of the damaged artery.

SUMMARY

Palliative care in head and neck cancer has not been s tudied systematically. Patients with incurable head and neck tumors may live months and even years. Ideal palliation should enable them to en- gage in a normal life before death ensues.

It is likely that our improving ability to treat these tumors wi thout achieving cures will cause people to live longer with their cancer. Hence, the need for palliation will probably increase. Also, treat- ments that cure patients p roduce condit ions that require palliation.

Achievement of the best possible function is the major consider- ation in dealing with head and neck tumors. Difficulty with speech, swallowing, oral hygiene, and malodorous tumors are all common. Depression too should be addressed in a comprehensive fashion by the ~head and neck team." The surgeon, radiotherapist, and medical oncologist will need help from dentists, prosthodontists , dental hy- gienists, psychiatrists, physiatrists, occupational and physical thera- pists, visiting nurses, nutritionists, and social workers. Palliative care in the hospital is the least desirable, although often unavoidable. Proper hospice suppor t will benefit patients and their families.

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Surgical palliation of head and neck cancer

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