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344
Manipal Manual of Surgery
• Double transverse
incision
• 3-point intersection is
avoided
• Subsequent blow outs
of carotid artery can
be avoided
• Furcate incision—
otherwise called
Y incision
• 3-point intersection
occurs which may
give rise to necrosis
Fig. 34.94: Functional neck dissection—blue nodes of papillary
carcinoma thyroid are unmistak
able
Figs 34.90 and 34.91: Incisions for block dissection: MacFee
and Crile
Fig. 34.92: Sternomastoid retracted
Fig. 34.95: Supraomohyoid neck dissection
Section II • General Surgery
Fig. 34.93: Radical neck dissection Fig. 34.96: Types of radical neck dissection
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
Fig. 34.97: Three types of neck dissections: Radical, modified
radical and selective
posterior scalp and neck. Can also be done
for thyroid malignancies.
d. Anterior neck dissection
• En bloc removal of lymph structures in level VI
• Perithyroidal nodes
• Pretracheal nodes
• Precricoid nodes (Delphian)
• Paratracheal nodes along recurrent nerves
Limits of the dissection are the hyoid bone,
suprasternal notch and carotid sheaths.
• Indications
–
Selected cases of thyroid carcinoma
– Parathyroid carcinoma
– Subglottic carcinoma
– Laryngeal carcinoma with subglottic extension
– Ca of the cervical oesophagus
IV. Commando’s Operation
RND, hemimandibulectomy with radical glossectomy.
It is a very radical and aggressive surgery done for
carcinoma tongue.
Investigations
. Complete blood picture
1
2. Chest X-ray can provide the following information:
• Secondaries in the lungs with cannonball appearance
as in cases of malignant melanoma of head and neck.
• Bronchogenic carcinoma can be suspected by an
irregular dense shadow in the peripheral lung fields.
• Large mediastinal node mass may be seen, with or
without tracheal shift.
3. Biopsy from clinically obvious lesion (tongue, cheek,
lips, etc.).
4. Triple endoscopy includes
• Direct and indirect laryngoscopy
• Oesophagoscopy
• Bronchoscopy and biopsy of the suspicious area.
5. X-ray base of the skull may show destruction of the
bone by the tumour.
345
6. CT scan of the sinuses, or nasopharyngeal area, or
skull base to detect a primary growth, its extension,
etc.
7. FNAC of the lymph nodes can give a diagnosis in
more than 90% of the cases, avoid incision biopsy
as it will result in tumour recurrence and wound
necrosis.
8. If primary tumour cannot be detected on endoscopy,
a blind biopsy is taken from posterior wall of the
fossa of Rosenmüller and of the pyriform fossa on
the same side.
9. When aspiration cytology is negative, an excision
biopsy is advised as a last resort.
INVESTIGATION AND MANAGEMENT OF THE
UNKNOWN PRIMARY WITH METASTASIS IN THE NECK
This is the challenging problem to clinicians to detect
primary and to treat the disease. When all investigations
fail to come to detect primary, and is called metastasis
of unknown origin.
Certain Facts
1. Even though primary is not found initially, rate of
emergence of primary tumour is about 3% per year.
2. About 10% of patients are cured of the disease but
primary is unknown.
3. About 20–30% of patients who have received
complete treatment die sometime later but primary is
still unknown.
4. Majority of occult primary nodes are located in level 2
and level 3.
5. Cystic malignant nodes in level 2 can be due to
oropharynx as occult primary and it will be squamous
cell carcinoma due to human papillomavirus.
6. Supraclavicular lymph nodes enlargement is due to a
few occult sites, such as bronchogenic carcinoma.
7. Clinical presentation of lymph nodes in the neck can
be solid or cystic lesions, or solitary or multiple
swellings. The swellings are usually located in level 2,
followed by level 3.
8. The clinical N stage at presentation is usually N2a,
N2b and N2c. The presence of cystic malignant
metastases in level 2 is usually due to human
papillomavirus (HPV)-related squamous carcinoma,
usually with subclinical primaries in the oropharynx.
Management Principles
1. All patients presenting with confirmed cervical
lymph node, metastatic squamous cell carcinoma and
no apparent primary site should undergo: Positron
emission tomography–computed tomography
whole-body scan.
Section II • General Surgery
346
Manipal Manual of Surgery
2. Bilateral tonsillectomy: Few consider this is not
necessary because if the lesion is very small-less than
0.5 cm, it will anyhow respond to radiation. So why
do tonsillectomy?
3. CECT is done from skull base to diaphragm.
4. MRI: If we suspect primary source in the tongue,
tonsil, etc. because of level 2/3 lymph node, MRI is
done. Extension of tumours in intratemporal fossa
can be better appreciated by MRI scan.
5. Panendoscopy: This is done to visualise the following
sites which cannot be examined clinically
• Tongue base Hard palate
• Tonsils Soft palate
• Posterior pharyngeal wall Vallecula
• Paranasal sinuses Post-cricoid fossa
• Nasopharynx Pyriform fossa
• Oral cavity Glottis, subglottis
Performance status should be assessed for major
6.
surgery, chemotherapy (ECOG page 681) or radiotherapy.
7. Concomitant chemotherapy with radiation should
be considered in patients with an unknown primary.
Concomitant chemotherapy with radiation should
be offered to suitable patients in the postoperative
setting, where indicated.
8. Neoadjuvant chemotherapy can be used in gross
‘unresectable’ disease.
9. Patients should be followed up at least two months
in the first two years and three to six months in the
subsequent years.
10. Patients should be followed up to a minimum of five
years with a prolonged follow-up for selected patients.
11. Positron emission tomography–computed tomography scan at three to four months after treatment
is a useful follow-up strategy for patients treated by
chemoradiation therapy.
12. Ultrasound-guided fine needle aspiration (FNA)
cytology and/or core biopsy under ultrasound
guidance. Most often, the report is squamous cell
carcinoma.
Treatment
Surgery is the main principle of treatment for N1 neck
nodes.
• If extracapsular spread is present, surgery should be
combined with radiotherapy.
• In advance diseases, surgery should be done after
chemoradiotherapy.
• Cisplatin is the drug of choice.
• The neck dissection is modified radical neck
dissection (MRND) including levels I–V.
• Summary of the treatment is given in Fig. 34.98.
Follow-up
• About 30–40% of treated patients with occult primary
with metastatic nodes die with no evidence of the
primary later.
• In about 30% of patients, the primary will manifest
within 1–2 years time.
• About 10% of patients are cured but primary is not
detected.
Section II • General Surgery
Fig. 34.98: Flowchart showing management of neck nodes
Cystic Swellings, Neck Swellings and Metastasis Lymph Node Neck
347
PANCOAST’S TUMOUR
• Pancoast’s tumour or superior sulcus tumour is a
bronchogenic carcinoma arising from the apex of lung.
• Typically, the patient is an elderly male around
70 years, chronic smoker who presents with cough,
weight loss, dyspnoea and chest pain.
• As the tumour grows, it compresses the lower roots
of brachial plexus C8 and T1 and results in tingling,
pain and paraesthesia in the distribution of ulnar
nerve.
• The tumour is felt in the lower part of the posterior
triangle. It is hard in consistency, fixed, irregular and
sometimes tender. The lower border of the mass
cannot be appreciated.
The Pancoast’s syndrome refers to the following
components
1. Pancoast’s tumour
2. Erosion of the first rib
3. Paralysis of C8 and T1 nerve roots
4. Horner’s syndrome due to paralysis of cervical sympathetic chain. The preganglionic sympathetic fibres
of the head and neck are given from the 1st and
sometimes the 2nd thoracic segments of the spinal
cord. These nerve fibres synapse with the cells in
the three cervical sympathetic ganglia. They give
rise to postganglionic fibres to the head and neck
region.
Thus, anywhere along this pathway, disruption,
damage or infiltration of the nerve roots results in
Horner’s syndrome. The causes of Horner’s syndrome
are depicted in Key Box 34.38.
Components of Horner’s Syndrome
• Miosis: Small pupil
• Anhidrosis: Absence of sweating.
• Pseudoptosis: Drooping of upper eyelid (Fig. 34.99).
• Enophthalmos: Regression of the eyeball
• Nasal vasodilatation: Nasal congestion
Key Box 34.38
Horner’s Syndrome
Common causes
Posterior inferior cerebellar artery (PICA) thrombosis
Cervical sympathectomy
Pancoast’s tumour
Uncommon causes
Syringomyelia
Injury to lower roots of brachial plexus
Tumour in the neck
Aneurysm of carotid artery
Fig. 34.99: Pseudoptosis due to Pancoast tumour
Investigations
• Chest X-ray: May demonstrate a dense mass or
collapse of the lobe, etc.
• CT scan may demonstrate infiltration of the tumour
into ribs or vertebra.
• Sputum for malignant cells
• Flexible bronchoscopy: Tissue biopsy or sputum
sample can be collected.
• FNAC of the tumour gives the diagnosis in majority
of cases.
Treatment
Palliative radiotherapy. The response rate is poor.
Section II • General Surgery
348
Manipal Manual of Surgery
1. Following are true for ranula except:
A. It is a swelling in the floor of the mouth
B.
It is a retention cyst
C. It is transilluminant
D. Plunging ranula produces one more swelling in
the submental region
2. Which one of the following does not give rise to
cross-fluctuation?
A. Iliopsoas abscess
B. Compound palmar ganglion
Sebaceous cyst
C.
D. Hydrocele en bisac
3. Following are true for thyroglossal fistula except:
A. Always congenital
It is lined by columnar epithelium
B.
C. Semilunar sign is seen in adults
D. Surgery done for this is called Sistrunk’s operation
4. Following are derived/arises from 2nd branchial arch
except:
A. Sternocleidomastoid muscle
B. Branchial cyst
C. Facial muscles
D. Anterior belly of the digastric
5. Which one of the following swellings does not
contain cholesterol crystals?
A. Branchial cyst
Sebaceous cyst
B.
C.
Dental cyst
D. Hydrocele
6. Most important stimulus for carotid body tumour
is:
A. Hypoxia B. Hyperbaric oxygen
C.
Hypothermia D. Hypercarbia
7. Tuberculous cervical spine can give rise to cold
abscess in following locations except:
A. Posterior wall of the pharynx in the midline
Behind the carotid sheath
B.
C. Front of the carotid sheath
D. Along the anterior primary division of the cervical
spinal nerves
8. Pancoast’s tumour has following features except:
A. It is a superior sulcus tumour
. It can give rise to Horner’s syndrome
B
C. It can erode first rib
D. It is usually resectable
9. Components of Horner’s syndrome are following
except:
A. Miosis B. Anhydrosis
Pseudoptosis
C.
D. Exophthalmos
10. Following organs drain to posterior triangle lymph
nodes:
A. Adenoids B. Thyroid
C. Retropharynx
D. Tonsil
11. Content of sebaceous cyst includes:
A. Desquamated epithelial debris
B. Keratin
C.
Sebum
D. Pus
Answers
1. D 2. C 3. A 4. D 5. B 6. A 7. C 8. D 9. D 10. D
11. B
Section II • General Surgery
35
Oral Cavity, Odontomes,
Lip and Palate
Oral cancer
Premalignant conditions
General principles in the treatment
Carcinoma of buccal mucosa
Carcinoma of tongue
Ulcers of tongue
Carcinoma of lip
Carcinoma maxillary antrum
Nasopharynx—cancer
INTRODUCTION
Oral cavity extends from vermilion junction of lips to
junction of hard and soft palate above and the line of
circumvalate papillae below or it is bounded by the lips
anteriorly, the cheek on each side, tonsils posteriorly,
superiorly by the palate and inferiorly by the floor of
the mouth. It is lined by squamous epithelium. Oral
cavity is a common site of malignancy because it is
insulted by various agents such as alcohol, smoking,
tobacco chewing. Oral cancer is the commonest malig-
nant neoplasm in the head and neck. Risk factors are
given in Key Box 35.1.
SU20.1: Describe etiopathogenesis of oral cancer
symptoms and signs of oropharyngeal cancer.
Abuse of tobacco and alcohol are the most common
preventable risk factors for development of head and
neck cancers. Those who smoke 2 packs/day and drink
4 units of alcohol/day have an odds ratio of 35 for
development of carcinoma. Tobacco quid is very
dangerous and highly carcinogenic.
An interaction occurs between redox-active metals
in saliva and low reactive free radicals in cigarette smoke.
Benign lesions in the oral cavity
Odontomes
Epulis
Median mental sinus
Vincent’s angina
Cleft lip and cleft palate
Ectopic salivary gland tumour
Mucous cysts
Key Box 35.1
Risk Factors Associated with Cancer of Head and Neck
Tobacco quid
Oropharyngeal Ca—Plummer-Vinson syndrome
Barr-Epstein virus
Alcohol, areca nut
Cigarette smoking and reverse smoking
Chronic irritation—dentures
Oral hygiene poor and poor nutrition
1
—‘Pan Masala’
2
Remember as TOBACCO
More than 70 to 100 carcinogens have been recognised in the tobacco
smoke such as nitrosamines, polycyclic aromatic hydrocarbons,
benzene, ammonia, arsenic, butanone, etc.
Net result is that saliva loses its antioxidant capacity
and instead becomes a potent pro-oxidant milieu.
Field cancerisation is a concept based on prolonged
exposure of oral and pharyngeal mucosa to carcinogens.
15 to 20% of the survivors of one cancer of head and
neck develop another primary head and neck cancer.
Oral cavity has many subsites which have been given in
Key Box 35.2. Importance of subsites (Fig. 35.1) is related
to different methods of management which has been
discussed later.
1
Betel nut chewed in combination with lime and cured tobacco is called ‘quid’. It is commonly placed in gingivolabial sulcus. It is highly carcinogenic.
This type of carcinoma is very common in India called Indian oral cancer.
2
Reverse smoking: Smoking a cheroot with burning end inside mouth. The risk of hard palate carcinoma is 47 times more in these patients.
349
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Manipal Manual of Surgery
Key Box 35.2
Oral Cavity Subsites
Lip Buccal mucosa
Lower alveolus Retromolar trigone
Oral tongue Floor of mouth
Upper alveolus Hard palate
Fig. 35.1: Oral cavity subsites
ORAL CANCER
Incidence of Oral Cancer
• Tongue : 50%
• Cheek : 20–25%
• Floor : 10–15%
• Gums : 10%
• Spices
• Spirits have synergistic action with smoking
• Sharp tooth, sepsis, poor oral hygiene
• Sunlight actinic rays
• Syphilis causes endarteritis obliterans and results in
chronic superficial glossitis of the tongue which is a
precancerous condition (rare these days).
Betel nut, and slaked lime with betel leaf and tobacco
(pan) is eaten and usually kept inside the cheek for
many hours. Over the years, it brings about chronic
irritation of mucosa of the cheek and causes leukoplakia. Tobacco contains multiple carcinogens including
aromatic hydrocarbons.
Stages in the development of leukoplakia
I. Keratosis appears as a milky blush on the surface.
I. Acanthosis refers to elongation of rete pegs. This
I
appears as a smooth, white, dry patch—smooth paint.
III. Dyskeratosis means the formation of keratin cell
layer in the deeper aspect of epidermis, before they
reach the surface—like wrinkled paint.
IV. Carcinoma in situ—warty.
V. Invasive carcinoma.
Speckled leukoplakia appears as multiple, small white patches
on an erythematous base. It has the highest rate of malignant
transformation (Figs 35.2 and 35.3).
Definitions
• Hyperkeratosis refers to increase in keratin layers. It
occurs due to constant irritation. Once the cause is
removed, it is reversible. It is a microscopic diagnosis.
For example, smokers’ hyperkeratosis of the palate
and lips. Once the aetiological agent is withdrawn,
the lesion returns back to normal.
• Leukoplakia appears clinically as a white patch in the
mouth and cannot be scraped off. It is irreversible and
not attributable to any known disease. It is important
to biopsy leukoplakic portion to rule out malignancy.
Sump area or ‘Coffin corner’ at the posterior tongue/floor of
the mouth is a common site for cancer—may be missed on
cursory inspection.
PREMALIGNANT CONDITIONS FOR ORAL CANCER
1. Leukoplakia
The causes for leukoplakia are as follows:
• Smoking results in hyperkeratosis. Nicotine in the
form of cigarettes, chewed tobacco, powdered snuff
Section II • General Surgery
produces premalignant changes in the oral cavity.
Treatment of Leukoplakia
• About 10% of leukoplakia patients develop oral
cancer. Hence, superficial excision of the lesion
followed by skin grafting should be done.
• Even though leukoplakia is irreversible, isotretinoin
(13-cis-retinoic acid) can reverse some cases of
leukoplakia and possibly reduce the development of
squamous cell carcinoma.
Fig. 35.2: Leukoplakia of the
tongue—biopsy was positive
for malignancy
with radiotherapy
(Courtesy: Dr Keerthilatha Pai, Dean and Professor, Department
of Oral Medicine, College of Dental Sciences, Manipal)
. He was treated
Fig. 35.3: Carcinoma arising
from leukoplakia
Oral Cavity, Odontomes, Lip and Palate
351
2. Erythroplakia is a red, velvety lesion with an
incidence of malignancy around 15% (17 times more
malignant than leukoplakia). It is irregular in outline
and may be nodular.
3. Chronic hyperplastic candidiasis (Key Box 35.3).
Key Box 35.3
Chronic Hyperplastic Candidiasis (Fig. 35.4)
Commissures of the mouth commonly affected
Albicans Candida invasion
No response to drugs, then surgery/laser treatment
Dense plaques of leukoplakia
Immunodeficiency can precipitate this condition
Dangerous because of malignant potential
Antifungal treatment—Topical application may help
Remember as CANDIDA
4. Submucous fibrosis
• This is supposedly
due to use of pan
masala, arecanut with
or without alcohol.
• Initially it produces
ulceration of mucosa
Fig. 35.4: Chronic hyperplastic
candidiasis affecting palate
of the cheek. These
ulcers heal resulting in a dense submucous fibrosis,
which appear clinically firm to hard. It can affect
the tongue also. It is a progressive disease entirely
confined to Asian population.
• Chances of malignancy are around 10–15%.
• Mouth opening may be restricted.
• It is treated by excision with reconstruction.
5. Sideropenic dysphagia (Plummer-Vinson and
Paterson-Kelly syndrome). Iron deficiency occurs in
the absence of anaemia in these patients. Common
in Scandinavian women. Iron supplements reduce
epithelial atrophy.
6. Papilloma of the tongue or cheek
7. Discoid lupus erythematosus
8. Dyskeratosis congenita
9
. Syphilitic glossitis: Tertiary syphilis produces
chronic superficial glossitis which can lead to
carcinoma of the tongue. However, it is rare these
days.
10. Human papillomavirus is an epitheliotropic virus.
Its oncoproteins suppress tumour suppressor gene.
It can give rise to tonsillar carcinoma and oropharyngeal carcinoma.
11. Miscellaneous: Saw dust—sinonasal adeno-
carcinoma.
• UV rays—lip cancer
• Reverse cigarette smoking—palatal cancer.
Upper Aerodigestive Tract Cancers
• Most of them are squamous cell carcinomas.
• Tobacco and alcohol are the most common aetio-
logical factors.
• Most common premalignant lesion is leukoplakia.
• Multiple anatomic sites can be involved simult-
aneously (synchronous).
• Second primary cancers develop in 10–15% of cases
(metachronous).
• Clinical presentation can be peculiar/misleading
depending on anatomic site.
• Generous biopsy and MRI (if necessary) are the
investigations of choice.
• Surgery, radiotherapy and chemotherapy are used
singly or in combination in appropriate cases.
Distant metastasis is more common with nasopharyngeal
carcinoma than with any other head and neck cancer.
COMMON SYMPTOMS AND SITES (Table 35.1)
Table 35.1 Common symptoms and common sites of oral
cancer (Ca: Carcinoma)
Symptom Site of cancer (Ca)
Pain around the eyes Nasopharynx
Pain in the ear (otalgia) Base of tongue, hypopharynx
Hoarseness Glottis
Trismus Extension of cancer into pterygoid
muscles
Dysphagia Base of tongue, hypopharynx,
oesophagus
Loss of hearing Auditory canal or nasopharynx
SU20.2: Enumerate the appropriate investigations and
discuss the principles of treatment.
GENERAL PRINCIPLES IN THE MANAGEMENT
Investigations
1. Wedge biopsy from the edge of the ulcer is taken
because of the following reasons:
• Tumour cells are concentrated more in the growing
edge.
Section II • General Surgery
352
Manipal Manual of Surgery
• Centre of the ulcer has slough.
• Histopathological report shows squamous cell
carcinoma and in majority of the cases it is welldifferentiated with keratin pearls.
2. Orthopantomography: X-ray of mandible to rule out
mandibular involvement (Fig. 35.5A and 35. 5B).
3. Chest X-ray to detect inhalation pneumonia.
Fig. 35.5A: Mandibular canal in a normal person is well away
from occlusive surface
Tumour spreads proximally and distally
within the cancellous
bone no further than
5 mm. So, 1 cm margin
and cut end of mandible is adequate
Fig. 35.5B: Mandibular canal in an edentulous patient is close
to occlusive surface explaining easy spread in carcinoma
buccal mucosa
AJCC—American Joint Committee Cancer staging
is followed uniformly while managing these patients.
TNM STAGING
Primary Tumour (T)
• T0: No evidence of primary tumour
• Tis: Carcinoma in situ
• T1: ≤2 cm with DOI (depth of invasion) ≤5 mm
• T2: >2 cm and ≤4 cm with DOI ≤10 mm
• T3: >4 cm with DOI ≤10 mm
• T4: Any cancer invading adjacent structures such as
cartilage, cortical bone, deep (extrinsic) muscles of the
tongue, skin or soft tissue of the neck.
T4a: Moderately advanced local disease.
T4b: Very advanced local disease (skull base, pterygoid
plate, internal carotid artery, masticator space)
Regional Lymph Nodes (N)
• Nx: Nodes cannot be assessed
• N0: No lymph node metastasis
• N1: Single positive ipsilateral node less than or equal to
3 cm in greatest dimension
• N2a: Single positive ipsilateral node more than 3 cm
but less than or equal to 6 cm
• N2b: Multiple ipsilateral nodes but all less than 6 cm
• N2c: Bilateral or contralateral lymph nodes but all less
than 6 cm
• N3: Lymph node more than 6 cm
Distant Metastasis (M)
• M0: No distant metastasis
• M1: Distant metastasis present
Stage Grouping
Stage I
Stage II T2, N0, M0
Stage III T3, N0, M0, TI–3, N1, M0
Stage IV T4, N0, M0 , T, N2–3, M0
Oral cancer—American Joint Committee
Cancer (AJCC)
T1, N0, M0
T0, N0, M1
4. Ultrasound guided FNAC of the lymph node.
5. Magnetic resonance imaging (MRI)
• Large advanced lesion can be better assessed by
MRI. Soft tissue infiltration can be assessed
correctly, thus dictating the extent of resection
especially in patients with restricted mouth
opening.
• It is the investigation of choice to look for involve-
ment of skull base, brachial nerve plexus, bone
marrow, spinal nerve roots and lymph nodes.
• MRI has no radiation hazards.
6. CECT is done when growth is infiltrating
Section II • General Surgery
mandible.
Aim of the Treatment
1. Cure of the patient: Cure of the cancer, if possible,
with wide excision of the tumour which includes
removal of the tumour with 1–2 cm of the normal
tissues, with or without bone.
. Palliation: If cure is not possible, palliation should
2
be attempted by surgery or radiotherapy.
3. Preservation of function such as swallowing, speech
and vision, should also be taken into consideration.
4. Cosmetic function: Following wide excision, the cosmetic function must be maintained by reconstruction
with myocutaneous/osteomyocutaneous flap.
5. To achieve minimal mortality and morbidity.
Oral Cavity, Odontomes, Lip and Palate
353
6. Metastatic lymph nodes are treated by neck dissection or curative radiotherapy (RT). Even when
nodes are not palpable, follow guidelines given in
Key Box 35.4.
7. When nodes are positive—refer to Key Box 35.5.
Key Box 35.4
Clinically ‘Node Negative’ Neck from Oral Cancer
Carcinoma lateral tongue, floor of mouth and mandi-
bular alveolus commonly cause occult metastasis.
Occult metastasis is seen in up to 30% of patients.
Hence, selective neck dissection of levels I, II and III is
indicated in continuity with tumour excision in these
cases.
Key Box 35.5
Clinically Node Positive Neck
N1 : Selective supraomohyoid neck dissection
{N2a and : Modified radical or radical neck dissection
N2b} followed by postoperative radiotherapy
N2c : Bilateral radical neck dissection—preserve
at least one internal jugular vein (IJV) +
postoperative radiotherapy
N3 : Preoperative radiotherapy, if feasible radical
neck dissection later
8. Treatment of advanced tumours—T3 and T4 lesions:
These are managed by combination of surgery with
postoperative RT. Usually, surgery is the principal
therapeutic modality of treatment followed by
postoperative radiotherapy. The treatment depends
upon general condition of the patient, risks of
anaesthesia, adequate intensive care management,
etc. Chemotherapy also has been tried before or after
surgery. However, response rate has improved but
it has not affected the survival.
• These are guidelines only, individualise the treatment.
Flowchart showing treatment of primary tumour and
metastasis is shown in Figs
35.6 and 35.7.
Role of Chemotherapy in Head and Neck Cancers
• The most important benefit of chemotherapy has been
in the treatment of laryngeal and nasopharyngeal
carcinomas.
• Cisplatin is clearly the most effective drug. Other
drugs such as carboplatin, 5-fluorouracil (5-FU),
bleomycin, gemcitabine, etc. are also used.
• Induction chemotherapy: In advanced cases, chemo-
therapy is given before surgery or RT. In more than
80% of cases, tumour regression can occur.
• Concurrent chemoradiotherapy (CCRT): It improves
both local and regional controls, specially in those
patients with high risk cancers, e.g. locally advanced
cancers of the oral cavity, larynx, oropharynx. Drug
Fig. 35.6: Treatment of primary tumour and metastasis
Section II • General Surgery