Head and Neck Cancer: Implications and Goals of Surgery and Reconstruction

What is the importance of early and long-term follow-up for survivors of head and neck cancer (HNC)? HNC survivorship begins with the diagnostic work-up and treatment planning. Cancer survivorship continues with HNC multidisciplinary team care coordination for early treatment management from pretreatment and during treatment. While treatment often provides a positive survival outcome and there is a cause for celebration, the HNC survival journey isn’t over yet. Long-term follow-up through HNC cancer surveillance and management of treatment-related symptoms is essential.

The complexities of HNC require a specialized, multidisciplinary team before, during and post-treatment for management of early and long-term tumor and treatment-related effects. In 2021, the incidence of HNC, specifically oral cavity and pharyngeal cancer, was estimated at 54,000 new cases, with 10,850 deaths in the US.¹ Intensive intervention from a team of head and neck surgeons, medical oncologists, radiation oncologists, nursing, and allied health staff is needed to preserve function, minimize detrimental treatment effects, and maximize functional recovery.

Historically, surgical interventions have been a primary treatment modality for HNC and continue to play an integral role with new surgical advances and other technology-based treatment options.

Understanding this journey, the goals of diagnosis and treatment, and what those treatment options may entail for the patient as they move into the future is critical to determining treatment options that will provide your patient with the best quality of life.

Head and Neck Cancer Diagnosis Goals

Diagnosing HNC involves multiple steps, including clinical examination and history, imaging, and pathology studies. Early identification of tumors of the head and neck is essential for improving survival outcomes.

Evidence-based practice guidelines and protocols guide HNC treatment recommendations and management. The following goals for diagnosing and managing HNC are paramount to achieving the best possible outcomes for your patients:

1. Reduce time to treatment to avoid treatment delays
2. Lessen treatment toxicities
3. Reduce anatomical collateral damage from extensive surgical procedures
4. Improve patient survival
5. Improve quality of life
6. Improve speech and swallowing outcomes
7. Improve nutritional status during and post-treatment

The Role of Epigenetics in Understanding HNC Progression

Epigenetics, or the study of how heredity influences gene expression in DNA sequences, contributes to our understanding of HNC progression and the potential for targeted therapeutics.

Epigenetics is critical for embryonic development, genetic imprinting, and X-chromosome inactivation; however, alterations or dysregulation of gene expression by the epigenetic system contributes to cancer development. More specifically, epigenetic changes (or disruptions) precede genetic variations and contribute to early neoplastic development or cellular transformation.

HNC disease progression is temporal and sequential, occurring with phenotypic, genetic, and epigenetic alterations. This altered progress contributes to preinvasive dysplastic cells from hyperplasia or dysplasia (mild, moderate, or severe) and potentially evolving into malignancy. The biology of HNC and the molecular mechanisms underlying head and neck squamous cell carcinomas (HNSCCs) provide opportunities for targeted therapeutics.

Head and Neck Cancer Management Goals

The main goal of HNC surgery and reconstruction is to get the cancer under control while optimizing functional outcomes. Multiple factors must be considered when planning reconstruction, including:

• Tumor size and stage
• Anticipated surgical defect
• Impact on function
• Previous HNC treatments
• Patient age and medical comorbidities
• Potential for airway compromise
• Preservation and restoration of physical appearance (cosmesis)

Advanced Surgical Treatment Options

Transoral robotic surgical approaches

HNC surgeons with specialized skills can perform minimally invasive techniques, such as transoral robotic surgical (TORS) approaches.

Compared to traditional open surgical approaches to oropharyngeal tumors, TORS approaches significantly decrease morbidity. Additionally, TORS approaches often have excellent oncologic results and can reduce a patient’s length of hospitalization from a week or more to two to four days, on average.²

Virtual surgical planning and 3D modeling

Virtual surgical planning (VSP) and 3D modeling are used to help manage complicated maxillary or mandibular reconstructions, particularly in patients with distorted, fractured, or missing mandibular segments. The head and neck surgeon planning reconstruction of the mandible and maxilla with the fibula osteocutaneous free flap may consider VSP and 3D modeling to improve surgical outcomes in cases requiring bony reconstruction.

Complex challenges are faced by the reconstructive surgeon, depending on the anticipated extent of the resection, structural relationships, and consideration of associated soft tissue defects. Careful planning is required to recreate the appropriate contours.

Curing the patient’s cancer is the primary goal of surgery and reconstruction; however, optimal functional outcomes are not always attainable for several reasons, including:

• Tumor size
• Location and extension
• Extracapsular spread (a predictor of poor outcomes)
• Adjuvant treatment-related toxicities

After surgery, optimal swallowing outcomes with flap reconstruction are highly variable and dependent on disease progression in the tumor stage, available reconstruction options, and factors specific to the patient. Reconstruction aims to provide good sensation, mobility, and appropriate flap volume to achieve better oral and oropharyngeal swallow function and efficiency.

You can learn more about the long-term impacts of head and neck cancer treatment and reconstruction on communication and swallowing along with the anatomy and physiology of HNC, tumor classification, cancer staging, and the factors influencing reconstruction options in the MedBridge course, “Head and Neck Cancer: Implications of Surgery and Reconstruction.”