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37 Principles ofManagement ofHead andNeck Cancers
413
the absence of demonstratable structural disease
in these subsites.
• Heterogeneous group of cancer arising
from the mucosa of the head and neck.
• Tobacco and alcohol abuse continue to
be the major etiological factors
globally.
• Increase in the incidence of HPV-related
oropharyngeal cancers which are biologically distinct and seen more in the
developed world.
• Signicant modication in the current
eighth edition AJCC staging system.
• Field cancerization resulting in second
primary cancers is common in tobaccoinduced cancers.
• History and clinical evaluation are
important to supplement imaging and
help plan appropriate treatment.
37.6 Treatment Philosophy
(Fig.37.1)
Multidisciplinary care by a specialized team
results in best outcomes. The core team responsible for planning and executing treatment must
include head and neck surgeons, radiation
oncologists, medical oncologists with inputs
from dedicated pathologists and radiologists.
Given that the goals of treatment are mitigating
morbidity in addition to achieving best outcomes, ancillary support is imperative. Good
plastic and reconstructive team, dentist, occupational therapist, physiotherapist, nutritionist and
speech and language pathologist should form an
integral part of the team. Given that a signicant
number of patients have a history of substance
abuse, psychosocial support is important. So
also, palliative care specialists should be integrated early in treatment plans in advanced
disease.
Establish diagnosis and extent of disease
Boipsy
Appropriate imaging
Tr iage patients for definitive and palliative treatment
Curative intent Stage I-IVB
Early stage I and II
Single modality
Surgery
• Oral cavity
• Sinonasal
• Select cases of larynx
(TLM), oropharynx
(TORS)
Radiotherapy
• Larynx
• Oropharynx
• Hypopharynx
Locally advanced stage III and IVA/IVB
Multimodality
Surgery followed
by adj RT/CRT
• Oral cavity
• Sinonasal
• Larynx/
oropharynx/
hypopharynx: if
unsuitable for
organ
preservation
(refer text)
Definitive CRT/bio
radiotherapy
• Larynx
• Pharynx
• Inoperable cases
Fig. 37.1 Treatment algorithm for head and neck can-
cers. TLM transoral laser microsurgery, TORS transoral
robotic surgery, PS performance status, RT radiotherapy,
Palliative intent
Recurrent/metastatic with
good PS
Not suitable for salvage
surgery or re-RT
Chemotherapy
• Conventional
• Ta rgeted
• Immunotherapy
Poor PS
Symptomatic supportive care
CRT chemoradiotherapy. Neoadjuvant chemotherapy usually not standard of care however considered in certain
indications, refer text
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A. K. D’Cruz et al.
Surgery and radiotherapy (RT) are denitive
treatments for head and neck cancers.
Chemotherapy is not curative by itself and is of
maximum benet only when used concurrently
with radiotherapy. It does not have an established
role in the neoadjuvant and adjuvant setting [25].
37.7 Stage IandII
Early stage (I and II) cancers are treated with single modality therapy either surgery or radiotherapy (RT) with similar outcomes and good control
rates ranging from 70 to 90% [26]. Site of disease,
accessibility, ease of treatment and morbidity of
treatment are factors that help choose between the
modalities. Patients’ preference, availability of
required infrastructure and expertise are other factors that inuence the decision. Surgery is the preferred modality for oral cavity and sinonasal
tumours as lesions involve or are in proximity to
bone [14]. In addition, surgery is simple, quick,
can be repeated and does not result in severe functional and cosmetic disability. Radiotherapy
(brachytherapy± external beam) is preferred for
supercial lip lesions particularly with commissure involvement and/or palatal lesions where surface mould brachytherapy avoids morbidity of
surgery [27]. Cancers of the larynx and pharynx
(oropharynx and hypopharynx) are usually treated
with radiotherapy given the functional morbidity
and/or technical difculty associated with surgery
at these sites. The advent of transoral laser microsurgery (TLM) and transoral robotic surgery
(TORS) made the larynx and oropharynx accessible enabling a select subset of patients to be
brought into the realm of surgery [14]. These
approaches avoid the morbidity associated with
open surgery and had the added advantage of
overcoming the sequelae and duration of radiotherapy. TLM could also be performed as a day
care surgery making it cost-effective [28].
37.8 Stage III andIVA
Given the advanced nature of these tumours,
treatment consists of a multimodality approach
[14]. Options include surgery followed by
adjuvant treatment (radiotherapy/chemoradiotherapy) or platinum-based concurrent
chemoradiotherapy (platinum occasionally
replaced by biologicals) with surgery as salvage.
As with early lesions, primary surgery is preferred for oral and paranasal sinus tumours.
There was a paradigm shift from surgical to
non-surgical approaches for oropharyngeal,
laryngeal and hypopharyngeal cancers. Until the
1990s, the treatment of stage III and IV cancers
in these subsites was primarily surgery followed
by adjuvant treatment [
29]. The philosophy
changed with the publication of the results of the
Veterans affairs laryngeal cancer study group
randomized controlled trial (RCT) in which
induction chemotherapy followed by radiotherapy in responders was comparable to surgery and
radiotherapy for outcomes with larynx preservation in two-third of patients who received nonsurgical treatment [
30]. Simultaneously a trial
designed on similar lines showed success for
hypopharyngeal tumours with this approach [31].
These two trials provided proof of principle that
surgery could be replaced by non-surgical organ
preservation strategies.
The landmark trial which established the role
of concomitant chemoradiotherapy (CRT) as
practised today was the Radiation Therapy
Oncology Group and the Head and Neck
Intergroup (RTOG 91-11) trial. Chemotherapy
followed by radiotherapy (I+RT), CRT and RT
alone were compared in a randomized setting.
The primary endpoint was larynx preservation
rate. Stage III and IV carcinoma larynx were
included in the study excluding small T1 and
large volume T4 disease (frank cartilage erosion
and disease extending >1 cm in the base of
tongue). At a median follow-up of 3.8years, larynx preservation was 88% vs. 75% vs. 70% with
CRT compared to I+ RT and RT alone respectively establishing CRT as the standard of care
32]. Long-term follow-up (median follow-up
[
10.8years) of the RTOG 91-11 trial continued to
show the benet of this approach with the larynx
preservation rates highest in the CRT arm [33].
The concomitant use of cisplatin RT was corroborated by MACH-NC meta-analysis [34].
The non-surgical approach was also found to
be successful for oropharyngeal cancers. The
AL GRAWANY
37 Principles ofManagement ofHead andNeck Cancers
415
GORTEC group compared RT vs. concomitant
CRT for the treatment of locally advanced oropharyngeal cancers. Patients received conventional RT in both the arms with the addition of
carboplatin (70 mg/m2 per day) and 5 FU
(600 mg/m2 per day) by continuous infusion in
concomitant CRT arm. There was an improved
locoregional control, 3-year actuarial OS and
DFS with CRT compared to RT alone arm [35].
Lesions not suitable for organ preservation are
those with bone or cartilage erosion (excluding
early perichondrial invasion), gross exolaryngeal
spread or a dysfunctional larynx when primary
surgery is offered.
37.9 Stage IVB
Stage IVB tumours technically constitute an
unresectable group and primary CRT (if patients’
performance status permits) is the treatment of
choice [36]. However, in certain select situations,
surgery may be offered when there is a possibility
of total tumour extirpation, e.g. low infratemporal fossa disease in oral cancers (refer Chap. 38).
The other option is the use of neoadjuvant chemotherapy (NACT) with an aim to downstage
tumour and offer surgery to responders [37].
NACT approach is usually applied to oral and
sinonasal tumours where the choice of primary
treatment is surgery.
37.10 Stage IVC
The goal of treatment is usually palliative with
chemotherapy. There are various regimes that
use a combination of conventional chemotherapy with or without the addition of biologicals
[38]. There is emerging data with exciting
results of immunotherapy in this group but the
majority of these publications explore its role as
second-line therapy [39–42]. Radiotherapy is
offered to metastatic disease most commonly
for painful bony metastasis. In the rare instance
of oligometastasis with a good disease-free
interval, surgery may be offered in highly
selected patients [43].
37.11 Principles ofTreatment
37.11.1 Surgery
The goal of primary surgery is en bloc excision
of the tumour with clear margins. There is no
role for palliative excisions with partial removal
of the tumour. Squamous cell carcinoma is biologically aggressive and resection of structures
such as an internal carotid artery, prevertebral
muscles/fascia is associated with signicant
morbidity and poor outcomes and hence are
signs of inoperability [14, 44]. Sinonasal
tumours have diverse histology and the grade of
the tumour guides treatment philosophy [21]. En
bloc resection is not always possible because of
technical and anatomical constraints. Piecemeal
resection which is at variance with the en bloc
concept has been accepted for laser excision and
sinonasal tumours. In these situations, adequacy
of resection is conrmed by frozen section control under magnication [45].
What constitutes an adequate margin varies
with the subsite of head and neck cancer. Margin
positivity is seen to be higher for oral and oropharyngeal cancers as opposed to larynx primary
[46]. Similarly, recurrent tumours have a higher
likelihood of having close or positive margins
[47]. The currently accepted norm for adequate
margins is considered to be 5mm [48]. Revising
the margin based on the frozen section is not
shown to offer benet and adequacy of resection
should be ensured at primary surgery [49]. Some
authors have suggested a lesser margin for oral
cancers but these ndings are not validated by
others and hence not standard of care [50].
Margins are known to shrink due to elasticity of
tissue post excision and subsequent to xation
and this should be factored in, at the time of excision [51]. Hypopharyngeal cancers are known to
have submucosal spread and margins wider than
5mm may be indicated [52]. For glottic larynx,
HPV-related TORS and sinonasal cancers lesser
margins are acceptable, considering the biology
and the anatomical constraints [53]. Margin sampling in these situations is patient-directed which
is at variance with specimen directed sampling
used otherwise [54–56].
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TLM, TORS and endoscopic sinonasal surgery are now a part of the treatment armamentarium of the head and neck oncologists. TLM is
used for early glottic (T1) cancers and shown to
have similar control rates to RT, superior voice
outcomes in select cases, is cost-effective and
with the added advantage of being possible as a
day care procedure [28, 57]. Moreover, salvage
by way of conservative procedures is still possible should recurrence occur as opposed to those
following radiotherapy where up to two-third of
patients need to have a total laryngectomy [58,
59]. It is widely recommended to be considered
as a suitable option across various guidelines.
The ideal case is a supercial mid cord lesion.
Laser excision has also been advocated for more
extensive glottic (T2/T3), supraglottic and hypopharynx tumours but has not gained universal
acceptance given the complexity of anatomy, the
technical difculty as well as the increased risk to
nodal metastasis in these patients. The general
dictum is that should the laser be chosen as treatment modality there should be no need for adjuvant therapy. Mopping up close or positive
margins following laser using adjuvant radiotherapy results in poor oncological and functional
outcomes. This dictum applies to the use of
TORS as well.
TORS is evolving as the treatment strategy for
early HPV positive oropharyngeal cancers though
current literature is not robust enough to justify
its use as the preferred modality (details in Chap.
38). Endoscopic sinus surgery has proven to have
excellent outcomes in terms of local control,
function and cosmesis. It has practically replaced
open surgery in suitable cases. Even with
extensive spread, it is used in combination with
the open procedure (endoscopic assisted).
Endoscopic resection is contraindicated in cases
with macroscopic dural involvement, the lateral
extension of the disease over the orbital roof, the
involvement of anterior and lateral portion of the
frontal sinus, invasion of the bony wall of the
maxillary sinus except for the medial wall, hard
palate involvement, erosion of the nasal bones,
extensive lacrimal pathway inltration and frank
orbital invasion [60, 61].
37.11.2 Reconstruction
Microvascular aps have replaced conventional
axial/pedicled aps for the majority of head and
neck reconstructions. These aps are associated
with high success (upwards of 90%) and better
cosmetic and functional outcomes [62, 63]. Use of
microvascular aps has enabled larger resections
as there is a lesser limitation on ap size and earlier rehabilitation with lesser dependence on tube
feeding and tracheostomies. Commonly used
microvascular aps are the radial forearm ap for
skin and mucosa, anterolateral thigh ap for skin
and soft tissue and the free bula ap for bone
replacement. Other aps like lateral forearm,
scapular, iliac crest have been described and used.
The merits and technicalities of each of these aps
are out of the scope of this chapter. Pedicled axial
aps such as pectoralis major myocutaneous
(PMMC), forehead and deltopectoral aps which
were once considered the workhorse of reconstruction have largely been relegated to history.
However, these aps are sometimes very useful
particularly in elderly patients, those unt for long
procedures, for recurrent cases and as salvage in
the event of microvascular ap failure. Local aps
are also useful for smaller defects. The general
dictum for reconstruction is like for like-bone
replaced by bone, soft tissue replaced by soft tissue, mucosa replaced by mucosa or skin.
37.11.3 Principles ofTreatment
ofNeck
Cervical node metastasis is one of the most
important factors that inuences outcomes in
head and neck cancers. Even a tiny metastatic
deposit irrespective of the size of the primary
upstages cancer to stage III. Appropriate management of the neck is therefore paramount in the
treatment of head and neck cancers. The modality of choice (surgery or RT) for treatment of the
neck is dictated by the modality chosen for treatment of the primary.
Selective neck dissection (SND) that samples
nodes at the highest risk of metastasis is largely a
AL GRAWANY
37 Principles ofManagement ofHead andNeck Cancers
417
staging procedure and usually done for a node
negative neck [64]. The levels of nodes sampled
are dependent on the site of the primary tumour.
Supraomohyoid neck dissection (level I–III) is
indicated for oral cavity and anterolateral neck
dissection (levels II–IV) for oropharynx, larynx
and hypopharynx cancers [65, 66]. There is data
to suggest the adequacy of SND (I–IV) for small
volume single node N1 in oral cavity cancers
given the low propensity to involve level
V.Modied neck dissection clearing levels I–V
saving all three non-lymphatic structures (sternocleidomastoid (SCM), internal jugular vein (IJV),
spinal accessory nerve (SAN)) is indicated for all
node positive cases [67, 68]. The larynx and
hypopharynx rarely involve level I and this area
is not treated for cancer at these sites. Radical
neck dissection is condemned in today’s day and
age. The IJV, SCM or SAN is sacriced on a case
to case basis only if directly involved by tumour.
In larynx and hypopharynx cancers, the contralateral neck is always addressed given the high
incidence of crossover lymphatics. For cancers of
the oral cavity and oropharynx, the contralateral
neck is addressed when the lesion reaches/crosses
the midline [69].
The clinicoradiological node negative neck is
electively treated even for small primaries of the
oral cavity which are excised per orally. There is
a level I evidence to show that this approach
decreases recurrences and improves survival [70,
71]. While anatomical boundaries should be fol-
lowed to ensure the adequacy of neck dissection,
the numerical number of 18 has been suggested
as an indicator of adequacy for cancers of the oral
cavity/oropharynx [66]. The sentinel node biopsy
has been advocated for cancers of the oral cavity
and oropharynx. It is shown to have high diagnostic accuracy as well as a negative predictive
value to the tune of 95% [72, 73]. However, given
the cost, steep learning curve, two-staged procedure, cumbersome pathology (serial step sectioning and IHC) and no real benet over a
well-performed SND, the procedure has not
gained universal acceptance.
Sinonasal tumours have a low propensity to
neck node metastasis given that this area is sparse
in lymphatics. The neck is usually not addressed
if clinicoradiologically negative. Extensive buccal mucosa or skin subcutaneous involvement
and high-grade histology are associated with a
higher incidence of neck node metastasis and
elective treatment of the neck should be considered. Glottic cancers similarly are sparse in lymphatics and the early glottic tumours do not need
the neck addressed.
37.11.4 Principles ofRadiotherapy
37.11.4.1 Denitive Radiotherapy
Radiotherapy, as mentioned earlier, is used as a
denitive treatment when surgical excision would
result in severe functional and cosmetic morbidity. It is used alone for early cancers stage I and II
of the oropharynx, larynx and hypopharynx.
Interstitial brachytherapy either alone or in combination with external beam RT is sometimes
used in select head and neck cancers (oral and
base of tongue). It is used alone for very early
lesions at these sites. An ideal case for interstitial
brachytherapy is a small lesion <3cm, supercial, away from the bone, accessible and node
negative [27]. Brachytherapy is also considered
at times in clinical practice following surgery as a
local boost to the tumour bed particularly for
localized, recurrent or persistent disease. For
locally advanced disease stage III and IV, current
standard of care is to combine RT with chemotherapy (chemorads) with better outcomes compared to RT alone [32, 35]. The recommended
chemotherapy is platinum-based cisplatin given
at the dose of 100mg/m
2
on day 1, 22 and 43 or
40 mg/m2 weekly [74, 75]. These are toxic
regimes with known complications and good
supportive care is essential. A cumulative dose of
cisplatin equivalent to 200mg2 should be aimed
for, proven to have better control rates.
At times patients are platinum unsuitable due
to advanced age, impaired renal function,
impaired hearing, pre-existing neuropathies,
compromised hepatic and cardiac function, poor
performance status, etc. Prior receipt of platinumbased neoadjuvant chemotherapy may also
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A. K. D’Cruz et al.
restrict the subsequent use of platinum chemoradiotherapy [76]. Replacing cisplatin with biologicals (cetuximab), carboplatin alone or in
combination with other chemotherapeutic agents
and altered fractionation are suggested alternatives [77]. However, these approaches have their
limitations. A meta-analysis specically comparing carboplatin to cisplatin RT while showing no
benet in terms of locoregional control was inferior in terms of overall survival (OS) in carboplatin RT arm [78]. Cetuximab RT does have
randomized evidence to show benet over RT
alone. However, this is a single trial with the
majority of oropharyngeal primaries and a signicant number of patients receiving altered fractionation RT which could be a confounding
variable [79]. In a subsequent systematic review
and meta-analysis comparing concomitant platinum-based chemotherapy or cetuximab with
radiotherapy for locally advanced head and neck
cancer, platinum- based CRT was associated with
better progression-free survival (PFS) and OS
[80]. Two RCTs since then, comparing cisplatin
RT vs. cetuximab RT in HPV-related oropharyngeal cancer showed that cetuximab RT was inferior in terms of tumour control, PFS and OS [81,
82]. Altered fractionation has shown to have a
similar 8% survival benet comparable to that
with chemoradiotherapy [83]. However, this is
rarely practised in most oncological units on a
daily basis for logistical reasons and toxicity.
Cisplatin RT, therefore, is the gold standard and
remains the rst choice when chemoradiotherapy
is considered.
Radio curable doses are aimed between 6600
and 7000cGy. Intensity modulated radiotherapy
is preferred to conformal radiotherapy and is
shown to have lesser treatment related side effect
particularly xerostomia [84]. There are different
dose and fractionation schedules applied in different situations and details of which are out of
the scope of this chapter.
37.11.4.2 Adjuvant Therapy
Adjuvant therapy is indicated for all stage III and
IV head and neck cancers. In addition, certain
stage I and II tumours may require postoperative
RT based on histopathological features that place
them at a higher risk for recurrence. Denite
indications for RT are T3/T4 tumours, close
resection margins and node positivity [
14].
Literature is divided on whether the benets
of adjuvant RT outweigh the morbidity in the
presence of other prognostic factors, namely
perineural invasion, lymphovascular invasion,
the grade of differentiation, DOI, single node
positive and worst pattern of invasion, known
to be associated with poorer prognosis.
Commonly used guidelines such as NCCN
place the onus on the treating clinician to consider RT in these settings. The general consensus is to assess the need on a case to case basis.
In the absence of clear-cut guidelines, a commonly used thumb rule is to recommend adjuvant treatment in the presence of two or more
of these factors [
85, 86].
Recently, depth of invasion has been incorporated in the AJCC eighth edition staging for oral
cancers placing tumours >10mm DOI as T3/T4
making this an independent indication of adjuvant RT.However, depth of invasion is strongly
associated with other adverse factors including
primary tumour size, pN category, ECS, and
close or involved margins. There was no benet
of PORT on disease-specic survival (DSS)
based on depth as an isolated factor in the absence
of other high-risk features in a multi-institutional
collaborative study. This study concluded that the
impact of DOI on DSS is through other adverse
factors and the decision regarding adjuvant RT
should not be based on DOI in the absence of
these features [
87]. This lends credence to the
fact that the combination of prognostic factors
may be the logical way to decide with regard to
the need for adjuvant RT.
Extracapsular spread or positive margins are
indications for postoperative CRT. Benets are
seen for this group of patients from the pooled
results of the two RCTs, Radiation Therapy
Oncology Group (RTOG) 9501 and European
Organization for Research and Treatment of
Cancer (EORTC) 22931 [88–90]. The recommended dose of chemotherapy is 100mg/m2 cisplatin once every 3weeks (day 1, 22 and 43) or
40 mg/m2 weekly. A lesser dose is associated
with poorer locoregional control as shown in an
AL GRAWANY
37 Principles ofManagement ofHead andNeck Cancers
419
RCT comparing 100mg/m2 3 weekly vs. 30mg/
m2 weekly [74, 75].
Postoperatively a dose of 5700–5800cGy for
low-risk patients and 6300–6400cGy for highrisk patients is recommended. There is no benet
with escalation above these doses. Factors considered for risk categorization are close or positive margins, nerve invasion, >2 positive nodes,
node >3 cm in size, treatment delay >6weeks
and performance status zubrod score ≥2, oral
cavity primary and extracapsular extension of
nodal disease.Early initiation and completion of
adjuvant treatment are associated with better outcomes. Patients who start RT within 6 weeks of
surgery or those who have a total package time
(TPT) dened as the time from the date of surgery to completion of radiotherapy ≤85days are
associated with favourable outcomes [91–93].
37.11.5 Principles ofChemotherapy
As mentioned earlier, chemotherapy is not denitive treatment by itself in the management of
head and neck cancers. The evidence in support
of chemotherapy emerges from meta-analyses
using individual patient data from 63 trials
(10,741 patients) published by the Meta-Analysis
of Chemotherapy on Head and Neck Cancer
(MACH-NC) collaborative group. The benet
was highest (8%) for concomitant chemoradiotherapy [25]. Updated results of 87 trials (16,665
patients) conrmed the highest benet of chemotherapy concomitant with RT [94]. These ndings were reconrmed by two further updates
from the same group with a larger number of
patients [95, 96]. When looking at benet across
the different subsites of head and neck cancers,
maximum benet was observed for the cancers of
the oropharynx and larynx [34]. Platinum chemotherapy was superior compared to other chemotherapeutic agents.
The role of chemotherapy in the neoadjuvant setting has been explored on many occasions in an attempt to improve outcomes. There
has been no signicant survival benet with
the use of chemotherapy in this setting [97].
However, neoadjuvant chemotherapy (NACT)
may have a potential role to help bio-select
favourable patients. Licitra etal. showed that
NACT downsized tumours making them more
amenable to smaller surgeries as well as a
decreased need for adjuvant RT [98]. Similarly,
Urba et al. used this approach to bio-select
patients for chemoradiotherapy and laryngeal
preservation [99]. Patil et al. likewise used
NACT to downstage oral cancers not considered suitable for primary surgery and brought
43% of patients into the realm of curative surgery [37]. While NACT continues to be used in
the clinic at the time of difcult decisions for
indications enumerated above it is not a routine
standard of care. If NACT is administered, the
ideal combination is the 3-drug regime of a
taxane added to cisplatin and 5-uorouracil
(5-FU) which has been shown to have superior
results over a 2-drug regime [100, 101].
37.12 Treatment ofRecurrent
andMetastatic Cancers
Recurrence is not uncommon in head and neck
cancers and can occur in up to half the patients
and depends on the initial stage and site of presentation. Salvage is possible in about fth of
these patients [102]. Recurrences may be difcult
to detect given post treatment alterations in anatomy and sequelae. Salvage surgery offers the
best chance at the cure [103]. It is prudent to
excise with wider margins than usual as it is often
difcult to distinguish between tumour and post
treatment induration. Adjuvant treatment if feasible offers a survival benet [104].
Re-radiotherapy is recommended if surgery is not
possible [105]. The success of salvage depends
on various factors that include the general condition of the patient, presence of comorbidities, the
initial and current stage of the disease, the receipt
of prior adjuvant treatment and most importantly
the disease-free interval (DFI). The longer the
DFI, the more the likelihood of salvage being
successful.
If surgery or re-radiotherapy is not possible,
palliative chemotherapy is the recommended
option. Doublet chemotherapy of cisplatin plus
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A. K. D’Cruz et al.
5-FU was the standard of care for a long time
[106]. The practice changed with data supporting the addition of cetuximab resulting in
improvement in OS [38]. Recently, immunotherapy targeting checkpoint inhibitors have shown
promising results. Both programmed cell death
ligand 1 (PD-L1) and programmed cell death
(PD-1) factor have been targeted in platinum
refractory recurrent and metastatic head and
neck cancers. Nivolumab and pembrolizumab
have shown survival benet as second-line therapy [39–42]. These drugs along with other
immunotherapeutic agents are currently being
explored as rst-line treatment. When the performance status is poor precluding chemotherapy,
patients are offered the best supportive and
symptomatic care.
37.13 Follow-Up
The majority of recurrences (≈90%) occur in the
rst 24months following treatment and recommendations are for more frequent follow-up during this period [107]. Moreover, patients need
care and rehabilitation from the morbidity of
treatment, which is most required during this
period. Recommendations for frequency of follow- up are every 2–3months for the rst 2years,
every 4–6months for the third year, 6 monthly
till fth year and annually thereafter. The frequency of follow-up may need to be varied on a
case to case basis and on patients’ symptomatology [14].
At each follow-up, a thorough locoregional
examination is performed to assess disease control. Second primary cancers are known to occur
(described in the section on natural history) and
a thorough examination of the entire upper
aerodigestive tract should be performed in addition. Late sequelae of treatment are also enquired
for, examined and addressed. The decision to
image at each follow-up is individualized
depending on the case and accessibility to the
examination but it is prudent to have a baseline
imaging at 12 weeks following completion of
cancer treatment that serves as a baseline for
comparison with subsequent imaging. Given that
at least half the patients who have received RT
have hypothyroidism, thyroid function tests are
ordered yearly [108]. The peak incidence of
hypothyroidism is 3 years post-treatment and
plateaus thereafter [109]. Dental examination
and uoride prophylaxis are recommended at
each follow-up to prevent radiation-induced caries. An annual chest X-ray is advised across
many guidelines particularly in smokers to rule
out the possibility of the second primary. A noncontrast CT scan serves as a useful alternative in
high-risk patients prone to lung cancers as its
ability to detect smaller lesions is superior.
Specic consultations with ancillary departments (e.g. physiotherapy, speech and swallowing, audiologist) are recommended based on
symptoms and sequelae of treatment.
• Surgery and RT are denitive treatments
for head and neck cancers.
• Chemotherapy has no role by itself
except in the recurrent/metastatic setting. Its benet in the curative setting
is when combined with RT
(chemorads).
• Early stage cancers warrant single
modality and advanced cancers multimodality treatment.
• Surgery should be performed en bloc
with adequate margins. A 5mm margin
is usually considered adequate. Lesser
margins are accepted for early glottic
cancers, HPV-associated oropharyngeal
cancers and low-grade paranasal sinus
tumours.
• Concomitant chemoradiotherapy is now
standard of care with an aim at organ
preservation for cancers of the oropharynx, hypopharynx and larynx.
AL GRAWANY
37 Principles ofManagement ofHead andNeck Cancers
Take Home Messages
• HPV infection is now recognized as an
etiological factor responsible for biologically different cancer from those traditionally caused by tobacco and alcohol
abuse.
• There has been the emergence of new
robust data (large pooled multiinstitutional databases, RCT and metaanalysis) which has resulted in paradigm
changes in staging, philosophy of treatment and management protocols.
• Oral and sinonasal tumours are primarily surgically treated while the pharynx
and larynx are primarily treated
non-surgically.
• Microvascular surgery, TORS, IMRT,
monoclonal antibodies and immunotherapy have expanded the scope of
treatment and also helped mitigate morbidity of treatment.
• Continued care during follow-up is
important for rehabilitation as well as
detection of recurrences/second primary
cancers.
Conicts of Interest None of the authors have any
conict of interest with respect to the manuscript.
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