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Head
and neck cancer can have devastating effects on a person’s
appearance and function. Organ preservation techniques
and complex surgical procedures such as skull-base surgery
and microvascular free flap reconstruction can successfully
treat the cancer while minimizing lasting damage.
In hindsight, it was
a good thing that Rick Ings fell off a ladder and hit
his head. Otherwise, he might have found out too late
that his sore neck and throat were not due to a muscle
pull or a cold, but rather, related to cancer.
“After the fall,
I went to a chiropractor, who advised me to see a head
and neck surgeon,” says Mr. Ings, a carpenter.
“The first doctor I went to said I had cancer
in my mouth, and he recommended surgery that would have
removed most of my tongue.”
Understandably, Mr. Ings
wanted a second opinion. Dr.
Erik Cohen, an assistant professor of surgery-division
of otolaryngology/head and neck surgery, and an attending
head and neck surgeon at University Hospital, agreed
with the diagnosis but recommended a different approach—organ
preservation.
For certain advanced
cancers in the head and neck area, such as in Mr. Ings’
tongue base (the back part of the tongue), an ears,
nose and throat (ENT) surgeon sometimes can offer a
treatment plan of chemotherapy and radiation that spares
the patient, at least initially, from surgery. This
treatment is called organ preservation. “For selected
patients, the results from organ preservation, when
combined with surgery for treatment failure, are as
good as surgery, but we are also able to keep as much
of the patient’s form and function as possible,”
says Dr. Cohen.
For Mr. Ings, whose chemotherapy
and radiation treatment lasted about two months, the
results couldn’t have been better. “The
cancer has been successfully treated without my having
to lose part of my tongue,” says the 53-year-old
Monmouth County resident, who also had some lymph nodes
removed. Many take the tongue for granted, but it has
important roles in speech and swallowing, in addition
to the sense of taste. Mr. Ings, like others who’ve
had organ preservation treatment, is grateful he did
not have to have surgery.
Similar
Success, Plus
Organ preservation treatment
began as an alternative to removing the larynx, or voice
box, of people with advanced-stage cancer of the throat.
“Previously, the only choice for these people
was a laryngectomy, the surgical removal of the voice
box,” says Dr. Cohen. “The patients lost
their natural ability to speak. A special device enabled
them to communicate, but with a robotic-sounding voice.
They also had a permanent tracheostomy.” Doctors
found that while the combination of radiation and chemotherapy
to treat advanced-stage larynx cancer, when combined
with surgery for treatment failure, had similar rates
of success to removing the tumor surgically, the former
approach enabled patients to retain their larynx and
better speech.
At University Hospital,
organ preservation treatment for the head and neck areas
most often is recommended for patients with advanced
cancers in the larynx, the tonsils, and the back part
of the tongue—areas where the approach has had
the most success. Organ preservation treatment involves
specialists from different disciplines, but most patients
initially are evaluated by one of the hospital’s
head and neck surgeons—Dr.
Soly Baredes, associate professor of surgery and
chief of the division of otolaryngology–head and
neck surgery at New Jersey Medical School, or Dr. Cohen.
“The gateway to treatment is usually the community
physician, who refers the patient suspected of having
cancer, to us. Either Dr. Baredes or I examine the patient,
perform a biopsy to confirm the diagnosis, and obtain
imaging studies to determine the stage of cancer,”
explains Dr. Cohen. If organ preservation is recommended,
the surgeons refer the patient to the team’s radiation
oncologists and the medical oncologists. The most complex
cases are discussed at weekly multidisciplinary tumor
board conferences.
The
Treatment
With organ preservation
at University Hospital, the patient typically receives
radiation and chemotherapy treatments at the same time.
Not only does this shorten the length of treatment,
but the chemotherapy sensitizes the tumor to the radiation
therapy. Often, says Dr. Cohen, the patient receives
chemotherapy once a week and radiation every day, both
over the course of several weeks. In Mr. Ings’
case, he was given chemotherapy for about six weeks
and radiation treatment during that same period, plus
another two weeks.
Organ preservation treatment
is not invasive like surgery, but patients could experience
the side effects of chemotherapy and/or radiation, and
many need a temporary feeding tube to maintain their
nutrition. “The throat can become extremely sore
due to the radiation, and by inserting a feeding tube,
a patient is able to keep going with the treatment and
maintain his or her weight and nutrition,” says
Dr. Cohen. “When treatment is stopped and then
starts up again, it is not as effective.” The
hospital can help arrange certain services, such as
home nursing visits to assist with the feeding tube
or even transportation so that a patient’s treatment
can stay on schedule. At certain intervals, most frequent
in the first two years after the radiation and chemotherapy
has ended, the patient will have follow-up visits with
the head and neck surgeon. If the tumor doesn’t
respond well or recurs, a “salvage surgery”
to remove the tumor might be recommended.
Dr. Cohen notes that
organ preservation is not the best choice for every
patient. The location of the tumor and its stage are
important factors when recommending the most appropriate
treatment. “For example, surgery alone might be
the best choice for a person with an early-stage cancer
in the mouth or someone whose tumor is growing into
the bone or cartilage,” he says.
However, for patients
who do meet the criteria for organ preservation treatment,
the benefits are clear. “Treating the cancer is,
of course, the priority,” says Dr. Cohen. “To
do so without taking away the person’s ability
to speak or swallow or without dramatically altering
his or her appearance is very much appreciated by the
patient.”
Advances
in Surgery
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| Dr. Parham Ganchi |
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| Dr. Ramazi Datiashvili |
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There have been advances
in the surgical treatment of head and neck cancers that
also improve “form and function.” “Years
ago, people who had head and neck surgery were often
left with obvious functional and cosmetic defects. The
tumor was removed, but not much could be done to restore
the contours of a person’s face or ability to
chew or swallow correctly,” says Dr. Cohen. “Now,
with a multi-disciplinary team and better reconstructive
techniques, we’re able to produce some excellent
cosmetic and functional results.”
One revolutionary technique
is known as microvascular free flap reconstruction,
or free tissue transfer. Simply stated, skin, muscle
or bone are taken from other parts of the patient’s
body to “fill in” gaps and defects. This
technique includes the intricate reattachment of tiny
blood vessels from the source tissue to vessels in the
new area.
Microvascular free flap
reconstruction is a complex technique that brings together
many specialties depending on the tumor’s location—most
notably, plastic surgery. In the case of head and neck
surgery, Dr. Cohen’s or Dr. Baredes’s role
would be to remove the tumor, while plastic surgeons,
such as Dr.
Ramazi Datiashvili or Dr.
Parham Ganchi, both assistant professors of surgery-division
of plastic surgery at New Jersey Medical School, would
harvest the tissue, place it in its new position, and
then reattach the blood vessels. “Microvascular
free flap is most often used for patients who are likely
to have a complex defect—when parts of the tongue
or jawbone are removed, for example,” says Dr.
Cohen.
Making
Tumor Removal Possible
Barbara Johnson has had
a major microvascular free flap procedure at University
Hospital, but to look at the 73-year-old, it’s
difficult to tell. Previously, in 2002, Mrs. Johnson
was diagnosed with cancer of a salivary gland, and the
gland and the tumor were removed by a local ENT surgeon.
“The operation went well, but he was concerned
because the tumor was a little larger than he had thought,
and it overlapped my jaw,” says Mrs. Johnson.
“However, with follow-up radiation treatment,
I had between an 85 percent to 90 percent chance that
the cancer would not come back.”
Despite the positive
odds, Mrs. Johnson’s cancer did return in 2004.
Upon finding that the tumor was more extensive than
he had hoped, the ENT referred Mrs. Johnson to Dr. Cohen.
The tumor extended behind her left cheekbone, down her
jaw and over to the edge of her eye socket. Because
of the tumor’s location near the skull base (where
the underside of the brain rests) and its complexity,
Dr. Cohen teamed with Dr.
Michael Schulder, associate professor of neurosurgery
at New Jersey Medical School, and Dr. Ganchi to develop
a surgical plan.
On September 24, 2004,
Mrs. Johnson underwent an operation that lasted 24 and-a-half
hours. During that time, part of her abdominal muscle
was harvested for the reconstruction. Parts of her left
jaw, cheekbone and the skull base were removed to excise
the tumor; then, Dr. Ganchi began the intricate job
of reconstructing Mrs. Johnson’s face and connecting
the blood vessels. “Removing the tumor would not
have been possible without the reconstruction,”
says Dr. Cohen.
Mrs. Johnson was at University
Hospital for about 12 days following the surgery. Her
recovery was not always easy or fast, especially when
it came to swallowing. A speech pathologist has worked
with her to regain the ability to swallow, and by January,
the nose-inserted feeding tube was removed and was replaced
by a tube that enters the stomach directly. Dr.
Edwin Deitch, professor and chair of surgery at
New Jersey Medical School, and his residents performed
that insertion. The Union County resident’s nourishment
also comes from special nutrient-packed drinks, while
a dentist from New Jersey Dental School is custom-making
a wearable plate for her that will line up her teeth
properly so she can chew. Nonetheless, she is pleased
with the progress she has made. Today, Mrs. Johnson
says, “I feel young and strong and enormously
fortunate to have found talented, dedicated doctors
like Dr. Cohen, Dr. Ganchi and Dr. Schulder, as well
as the outstanding staff at University Hospital. I am
amazed at all that’s been accomplished.”
Jozef Korec is another
of Dr. Cohen’s patients who has benefited from
a microvascular free flap procedure. The 58-year-old
Morris County man had surgical removal of a tumor from
the floor of his mouth and lower jaw. In April 2004,
Dr. Cohen and Dr. Ganchi worked together, removing the
tumor and then reconstructing his jaw with a piece of
bone from Mr. Korec’s fibula. While the rehabilitation
period took time and was sometimes challenging, he looks
and feels great.
“Two times now,
my life has been saved at University Hospital,”
he says. “First by Dr.
David Livingston, the trauma surgeon who operated
on me after I was involved in a trauma a few years ago.
This time, it was Dr. Cohen, who removed my tumor, and
Dr. Ganchi. I am very thankful again.”
To
arrange for a consultation with Dr. Erik Cohen or Dr.
Soly Baredes, please call 973-972-2548. To learn more
about treatment options for head and neck cancer, listen
to Dr. Cohen's recent appearance on HealthLink Radio.
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