H&N overview of surgical therapy

Question 1

What are the three major categories that should
be considered when determining candidacy for
surgical intervention for head and neck cancer
patients?

Answer 1

● Physiologic: Cardiorespiratory fitness, coagulation status,
immune status, and weight loss (> 10% body weight
considered poor prognosticator for surgical intervention)
● Anatomical: Surgical access to the subsite of interest
(e.g., trismus in oropharyngeal cancer, brittle cervical
spine or large osteophytes in laryngeal cancer)
● Oncologic: Ability to achieve surgical margins, acceptable
morbidity with complete resection

Question 2

When considering surgical management of a
primary head and neck tumor, what is a critical
component of successful management?

Answer 2

Ability to achieve negative margins

Question 3

For upper aerodigestive tract tumors, what is the
minimum width of tissue that must be taken to
achieve a negative margin?

Answer 3

Controversial. The presence of invasive carcinoma in the
margin specimen is the only factor that indicates a positive
margin. In many subsites, width cutoffs have been
abandoned for narrow margin analysis resulting from the
proximity of critical adjacent structures.

Question 4

True or False. En bloc tumor resection is the only oncologically sound method for surgical management of a primary head and neck tumor.

Answer 4

False. Narrow-margin analysis, “bread-loafing,” or tumor
mapping with frozen pathologic analysis of margins does
not compromise oncologic outcomes (Hinni, 2013).

Question 5

When a tumor invades a sensory or motor nerve,

what is the recommended surgical approach?

Answer 5

Dissect proximally and distally along the nerve, take
margins at either end and with the goal of obtaining
negative margins on frozen section analysis.

Question 6

In a patient with biopsy-proven squamous cell
carcinoma metastases to the cervical lymph
nodes, what are the most likely site and subsite of
origin?

Answer 6

Unknown primary:
● Site: Upper aerodigestive tract
● Subsite: Oropharynx

Question 7

Why is it clinically important, from both a prognostic and management standpoint, to identify the site of origin for an unknown primary tumor?

Answer 7

Failure to identify the site of origin results in
● Significant decrease in 5-year overall survival (50%)
● Need for wide-field radiation therapy with an increase in
associated morbidity

Question 8

What imaging modality can be helpful in identifying the unknown primary in as many as 30% of TX head and neck cancer patients?

Answer 8

PET/CT scan

Question 9

Describe the surgical approach for a patient with

an unknown primary tumor.

Answer 9

● Manual palpation of the upper aerodigestive tract
● Visual inspection using naked-eye evaluation, rigid
endoscopy, laryngoscopy and microscopy
● Directed biopsies and frozen-section analysis. If negative,
proceed.
● Palatine and lingual tonsillectomy with frozen-section
pathology ipsilateral to the cervical adenopathy. If nega-
tive, proceed.
● Contralateral palatine and lingual tonsillectomy with
frozen-section pathology. If negative, proceed.
● Nasopharyngeal biopsies with frozen-section pathology. If
negative, proceed.
● Neck dissection and permanent serial sectioning of the biopsy specimens
Note: If tumor is identified at any step, complete resection is
advised. (Karni, 2011; Nagel, 2013).