The Intricate Nature of Head and Neck Cancer Surgery

Additional Info

• Audio File:uab/ua051.mp3
• Doctors:Greene, Benjamin;Hughley, Brian;Buczek, Erin
• Featured Speaker:Dr. Benjamin Greene | Dr. Brian Hughley | Dr. Erin Buczek
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=2049
• Guest Bio:Dr. Benjamin Greene is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University at Buffalo, School of Medicine and Biomedical Sciences and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
  
  Learn more about Dr. Benjamin Greene
  
  Dr. Brian Hughley is an ENT-otolaryngologist in Birmingham, Alabama and is affiliated with University of Alabama at Birmingham Hospital. He received his medical degree from University of Virginia School of Medicine and has been in practice between 6-10 years. He is one of 12 doctors at University of Alabama at Birmingham Hospital who specialize in Otolaryngology.
  
  Learn more about Dr. Brian Hughley
  
  Dr. Erin Buczek is an otolaryngologist-head and neck surgeon provides comprehensive medical and surgical care for patients with diseases and disorders that affect the ears, nose, throat, the respiratory and upper alimentary systems and related structures of the head and neck.
  
  Learn more about Dr. Erin Buczek 
  
  Release Date: December 6, 2017
  Reissue Date: December 4, 2020
  Expiration Date: December 4, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Brian B. Hughley, MD
  Assistant Professor in Otolaryngology,
  
  Erin Buczek, MD
  Assistant Professor in Otolaryngology,
  
  Benjamin J. Greene, MD
  Assistant Professor in Otolaryngology,
  
  Drs. Buczek, Greene and Hughley have no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole: (Host): Every year, approximately 100,000 people in the United States are diagnosed with head and neck cancer. Here today, in a panel discussion regarding the intricate nature of head and neck cancer, facial reconstruction, and how it affects the daily lives of patients, and their families are Dr. Benjamin Greene, Dr. Brian Hughley, and Dr. Erin Buczek. They are Head and Neck Surgeons at UAB Medicine. Welcome to the show, Doctors. Dr. Hughley, I’d like to start with you. Explain a little bit about head and neck cancer. How common is it, and are there different types?
  
  Dr. Brian Hughley (Guest 1): Yeah, there are several different subtypes, mostly based on the area in which they occur. In my last reading, about the fifth most common cancer in the United States – so not very rare, but not nearly as common as some of the more common ones. We typically divide these up – there are several different ways to divide it up. Most people, when they think of head and neck cancer, think of the upper aerodigestive tract – basically the track starting from the lips going down to the voice box including mouth cancer, tongue cancer, throat cancer, voice box cancer or a lot of the other names that they go by, but they also include skin cancer of the head and neck and endocrine cancers of the head and neck, like thyroid cancers and salivary gland cancers.
  
  Melanie: And Dr. Buczek, give us a little pathophysiology. What are some common conditions and factors that lead to head and neck cancer and who might be at risk?
  
  Dr. Erin Buczek (Guest 2): Well, that’s a great question. Traditionally, most head and neck cancer are caused by squamous cell carcinoma, which is the most common histologic type of cancer that we see. In the aerodigestive tract, traditionally, the risk factors have been tobacco use, including cigarettes and smokeless tobacco, as well as heavy alcohol usage. In the recent couple of decades, we’ve noticed a sharp increase though, in HPV-mediated cancer – similar to cervical cancer, Human Papilloma Virus has been found to be associated with particularly oropharyngeal cancers, which are tonsil cancers and base of tongue cancers. We’ve seen that split of a group of tobacco and alcohol-related and then HPV-related cancers.
  
  Additionally, we sometimes see skin cancers like Dr. Hughley mentioned, so they are associated with sun exposure, and then some of the endocrine cancers can be associated with a familial -- hereditary factors as well.
  
  Melanie: And Dr. Greene, what is the clinical presentation of head and neck cancer? What would even send somebody to see a physician?
  
  Dr. Benjamin Greene (Guest 3): That’s a good question because they can be masked as other – they can be easily missed because they can come up as a sore throat, they can come up as hoarseness of your voice, they can come up as ear pain, and they can also come up as just a lesion on the tongue that won’t go away or something like that. Somebody that has hoarseness for a long time may not think of that as being cancer, and their doctor may not think of that as being cancer either, and they won’t know that something is wrong until a lump comes up in their neck. And actually, a lump or a large lymph node in the neck is sometimes the first thing that we see with these. That’s why I always tell people that if you’re over 40 and you have a new lump in your neck, you have to come and see a head and neck surgeon or an ear, nose, and throat doctor to have that evaluated because we have to start thinking that that’s cancer until proven otherwise. And that’s because they can mask as so many other things. I’ve seen people who just have ear pain, some people who just have some pain in their throat and all of a sudden, they have a very large cancer back there that was just missed because of the seemingly benign nature of their symptoms.
  
  Melanie: Dr. Buczek, how important is early diagnosis as being crucial to improve the outcome prediction?
  
  Dr. Buczek: Early diagnosis is extremely important, not only to catch cancers early and treat them when they’re small, but head and neck cancer is a rarity in the sense that treatment affects so many important different functions, so for instance, speech, swallowing, and even breathing can be severely affected if these cancers progress. If we can catch them early, a lot of times that will have a dramatic impact on folk’s functional outcomes as well as survival outcomes. Once you get to an advanced stage, local cancer, it can be pretty difficult to cure, even with aggressive surgery and radiation, and so early diagnosis is critical.
  
  Melanie: Dr. Hughley, what are some valuable prognostic tools to aid in that early diagnosis?
  
  Dr. Hughley: The very first thing we always start off with is a good, and thorough physical exam, but that includes in – like Dr. Greene was saying, in either an ear, nose, and throat physician’s, or specifically a head and neck surgeon’s office. We can look in the back of the throat and down at the voice box very easily with no sedation, no special equipment other than what we have in the office. We’re able to look at people and look at the back of the throat in the office and get our first impressions. After that, other things that we do very frequently as far as imaging is Commuted Tomography – or CT scans, occasionally MRIs, Ultrasounds, things like that that we can order based on what we see in person and on a patient’s symptoms. PET scans are another thing that is frequently used, and other diagnostic tools that we have -- occasionally in the office we can do biopsies or needle biopsies. Sometimes those have to be sent out and done by our radiology colleagues using some image guidance.
  
  Melanie: Dr. Hughley, I’m going to stick with you for a minute – to the sensitivity of this cancer and the intricate nature, are there some non-surgical treatment options if you detect there’s something going on?
  
  Dr. Hughley: There absolutely are. In some cases, surgery isn’t necessarily the first line treatment. We work in – every one of these cancers – or at least locations of cancers can be treated and is best treated in a place that has a multidisciplinary approach. The common ways to – there are basically three ways to come at the treatment of head and neck cancers. There’s surgery, there’s chemotherapy, and there’s radiation therapy. We work very closely with our medical oncology and radiation oncology colleagues to come up with the best treatment plan based on the location of the disease, the type of disease, and the extent of disease.
  
  Melanie: Dr. Buczek, who is involved in the surgery, and the aftercare? Tell us a little bit about the cancer care team for head and neck cancers.
  
  Dr. Buczek: Absolutely, it involves several different players. You have the head and neck cancer surgeon themselves. There are clinical care coordinators who are specifically specialized in cancer care who our patients will meet in the clinic when they are diagnosed with cancer. There’s an anesthesia team, which can be extremely important particularly from an airway standpoint – a lot of these cancers involve the airway, so they are a vital member of the team. Afterwards, there’s a whole team of surgeons and residents taking care as well as our amazing nursing staff. A lot of the surgeries that we do are fairly specialized and require things such as tracheostomies and feeding tubes, and that requires a lot of specialized nursing care as well. Here at UAB, we have a dedicated floor where our head and neck cancer patients go, and the nurses there are specialized in taking care of this type of patient.
  
  After that, as Dr. Hughley mentioned, it’s a team approach when it comes to radiation therapy, possibly chemotherapy, and using our medical and radiation oncology colleagues. At the same time, we’re also utilizing our pathology colleagues as well, both in the operating room – we often will send samples of tissue from the tumor that’s removed to make sure that we completely excise it – and then afterwards, they’re evaluating the tumor that we send them as well as any lymph nodes or other structures that are resected.
  
  And then last but not least, our radiology friends are helping us determine exactly where the tumor is on imaging and helping us plan surgically what needs to come out. It’s a big team effort.
  
  Melanie: Certainly a multidisciplinary approach. And Dr. Greene, please start for us, with the goals of reconstruction for the patient, protecting vital structures, function, form, and the sensitivity of this procedure.
  
  Dr. Greene: Reconstructing the head and neck is very difficult because – think of everything that you have to do using your throat, your mouth, it’s not only speaking or breathing but eating and all of these things – and cosmetics. All of these things are part of what makes us human beings. In my own personal social life, eating is basically 98% of what I do socially with my wife, my kids, my friends, everybody. If you take away somebody’s ability to eat, that’s a big deal for them and their quality of life. Breathing without a tracheostomy tube, that is – having to have a tracheostomy tube or feeding tube, and just your cosmetic appearance is extremely important to people.
  
  When I talk to people about surgery, I say there are multiple goals of surgery. The first and most important goal is getting all of the cancer out safely. That’s the most important goal. But then we have to talk about the goals of reconstruction, and I always tell people, the first, primary goal of reconstruction is making a safe wound where you don’t die from the wounds that are created by taking the cancer out. I don’t say that lightly because these are wounds that are created where saliva could potentially be coming to the neck from a space where saliva is supposed to be – in the oral cavity – to a space where it’s not supposed to be in the neck. Saliva contains a ton of bacteria and also proteinases that dissolve proteins. If saliva leaks into your neck, you can have major infections, and if it erodes into your blood vessels you can have major bleeding and even death. The main goal of reconstruction is to seal the oral cavity from the sterile environment of the neck. That’s number one.
  
  Number two is a functional recovery, which means getting people to eat without a feeding tube safely so that it doesn’t aspirate and go into their lungs. With that, breathing without a tracheostomy. Eating without a feeding tube, breathing without a tracheostomy. I tell people my last goal is cosmetics. Even though it is important, it is the least important goal of reconstruction because if you think about it, dying from the wounds is about as horrible as it could be. And then if you still have a feeding tube and a tracheostomy tube, those parts of your life become more important to you than cosmetics. While cosmetic recovery is a very, very large goal of what I do, it is probably – believe it or not – the least important. So that’s the goal.
  
  We, as head and neck surgeons, are very comfortable understanding the anatomy of how people speak and swallow and we work very, very closely with our speech pathology and head and neck speech and swallowing team to make sure that they’re seen preoperatively, during their hospitalization, and followed postoperatively to make sure that their speaking and swallowing outcomes are as good as we could possibly get them.
  
  Melanie: Dr. Hughley, you had mentioned some nonsurgical techniques and adjuvant therapies that might possibly go along. What about IORT, Brachytherapy, or Palliative Radiation Therapy? Speak about some of these adjuvant therapies and when would be the appropriate times to be using those?
  
  Dr. Hughley: Nonsurgical therapy can occasionally be used as primary therapies, specifically in the oropharyngeal cancers, tongue base, and tonsils, as well as some of the early stage laryngeal cancers. Often times in large cancers, usually in more advanced stage cancers, after we have done surgery they’ll need adjuvant therapy – usually radiation, occasionally chemotherapy based on certain indications from the surgery to go along with that whether there is evidence that there is a potential for microscopic disease left behind, or if there are grossly positive margins and not all of the cancer is able to come out.
  But more commonly, we think about postoperative adjuvant therapy as radiation used in addition to surgery to help with the more advanced stage three and stage four cancers.
  
  Most of – you had mentioned IMRT. That’s the standard radiation protocol that I’m aware of in the modern era of head and neck cancers and has a big benefit to patients as far as the side effects that they have, which are usually much more – I’m sorry, not more – are less with IMRT. That’s another one of the advantages of coming to a place – or having your treatment at a place that has a high volume of the specific type of cancer you have.
  
  Melanie: Dr. Buczek, as we’re talking about this intricate procedure and the adjuvant therapies, and then there is the patient to consider – and Dr. Greene mentioned a little bit about the self-esteem and the look after surgery, and all of these really important functions that the head and neck do – eating – and all that goes into that. How do you deal with the families? What are some of the effects in the daily life that you explain to these families, and you say this is how your new normal would be or how we’re going to deal with it? For other physicians, what do you recommend about discussing this type of treatment with families?
  
  Dr. Buczek: That’s a very, very good, and complex question. I would say when we see a new patient and are discussing surgery; I think it’s very important to be honest with patients up front. It can be really terrifying for them to hear exactly what surgery is going to entail, but I have found that people that are well prepared do a little bit better than if they are surprised after surgery. Explaining to them exactly what’s going to need to come out and what things will look like after surgery, for instance, how their speech is going to be affected. Let’s say, for instance, the patient as a big tongue cancer, how are they going to talk afterward? I think explaining to them that how things are two days after surgery is very different than how things can potentially be three or four months after surgery in that a lot of folks with a lot of speech pathology and exercises can really regain a lot of function that they started off with depending of course on how big the tumor is. And then having our speech pathology colleagues see them in the clinic – like Dr. Greene said, before surgery – to really help explain how things are going to work.
  
  One of the more common things we do here at UAB is something called a laryngectomy where we take out someone’s entire voice box. When someone hears that they’re going to lose their voice box, that’s fairly devastating news, but in reality, a lot of folks do pretty well long-term, and they’re able to communicate, just in a different way than what they were used to preoperatively. Taking the time to explain how it’s going to work, explain their new physiology because things are extremely different than what they’re used to, I think that really helps alleviate their fear that they’ll never be able to talk again when in reality they potentially can, it’s just going to be different. I think that makes people feel better.
  
  And then from a more personal standpoint, we, here at UAB, have a head and neck cancer support group that meets every – I believe every other month. I feel like that’s a really great resource for a lot of our patients who can meet other patients who’ve gone through something similar. While we see a lot of this, it is not particularly common in the community and, so it can be really hard to reach out and find resources, but just knowing that they’re out there can be really helpful.
  
  Melanie: Dr. Greene, as far as things that are so complex like mandibular reconstruction, what kind of additional training do you have to do these kinds of complex procedures, and what would you like other physicians to know about entering into this field?
  
  Dr. Greene: There are a couple of different ways to become a head and neck reconstructive surgeon. I’m an ear, nose, and throat doctor, and so I did four years of medical school, five years of Otolaryngology – or ENT residency – and then one year of Head and Neck Cancer and Reconstructive Microsurgery Fellowship. Dr. Hughley and Dr. Buczek did the same. That’s one way – five years of an Ear, Nose, and Throat Residency plus a Head and Neck Cancer and Reconstruction Fellowship.
  
  Now, there are other ways – Plastic Surgeons do this on a routine basis, and going into a Plastic Surgery Residency from medical school or doing a Plastic Surgery Fellowship after Surgery. Oral Surgeons can also do this, so Oral Surgery Residency plus a Reconstructive Head and Neck Cancer Fellowship after Oral Surgery Residency.
  
  For the most part, in this country, the most head and neck cancer reconstructive surgery is being done by Ear, Nose, and Throat doctors who have specialized training in reconstructive surgery for the head and neck. That’s a shift over the past twenty years or so because otolaryngologists, for the most part, are the people who diagnose these problems that are sent because they have a sore throat, or they have a lump in their throat or a mass in their neck, we tend to see these people, treat them, and reconstruct their cancers as needed.
  
  Melanie: Dr. Hughley, what does current research indicate for future developments and treatments? Give us a little blueprint of what you might see as future research and if there’s anything you’re doing at UAB that other physicians might not be aware of.
  
  Dr. Hughley: As far as for reconstruction, some of the newer concepts or newer techniques being used involve 3D modeling of the actual reconstruction – particularly with the complex bony reconstruction. We can look beforehand at a CT scan of the patient and realize which parts are going to be removed with the surgery and which parts need to be reconstructed, and then can use computer software along with specialized engineers to design the shape of those bony reconstructions, whether it’s the mandible or the mid-face or even some cranial bone defects. That’s something that’s become almost standard now – we’re doing that fairly routinely.
  
  Other advances that are being made – or newer things not related to reconstruction are the robotic surgeries that we’re doing. Actually, a lot of the initial research that was done on using the robotic surgical instruments for head and neck cancers was actually done here at UAB and was one of the institutions that helped pioneer that. We’re currently – all three of us who you’re speaking with today as well as our Chairman, Dr. Carroll, are doing robotic head and neck cancer surgery. We’re helping pilot a new training program for our residents along with – it’s a multidisciplinary training program for robotic surgery along with our gyn, and urology, and general surgery colleagues that we’re going to be one of the first institutions in the nation to institute this multidisciplinary residency robotic training program. Those are a few of the things that we’re going with head and neck cancer that are sort of – I guess you could say are on the cutting edge and things that are being pioneered here at UAB.
  
  Melanie: Dr. Buczek, last word to you. Tell other physicians what you’d like them to know about head and neck cancer surgery, reconstruction, and when to refer to a specialist.
  
  Dr. Buczek: I would say when to return to a specialist would be anytime you’re unsure – if someone has a neck mass, or a lesion in their oral cavity, or hoarseness that’s persistent, especially in an adult, I would refer to an ear, nose, and throat physician within at least a month or two if it’s still persistent and fails conservative management.
  
  As far as head and neck surgery and what I would tell other physicians, I would say if you’re uncomfortable and you’re uncertain with the anatomy or with the particular disease, referring to a high-volume center is usually best. As we talked about in the last few minutes, there are so many different aspects to head and neck cancer, and it’s very complicated, and I think the best care can really be given in a place where they have all of those resources. I would suggest to anybody who is uncertain or may not feel like they may not have those resources, that’s the time where I would be sending that to a tertiary care center here, like UAB.
  
  Melanie: Dr. Greene, what can a physician expect from your team after referral, insofar as communication with the referring physician and your team approach?
  
  Dr. Greene: Well, basically, whenever somebody refers over to us, we like to keep an ongoing communication line with the people that sent it because when you’re at a place like UAB in Birmingham, we’re getting people from Tennessee, Georgia, Mississippi, the Florida Pan Handle five hours away. The aftercare – when folks go home from the hospital, we’re going to rely on the people who initially referred the patient to help us with the aftercare, whether it’s something simple like pulling out a drain, so they don’t have to make a five-hour trip for that, and also, taking care of people who have emergent problems in the Emergency Department.
  
  What I like to do is see the patients and send the doctor who referred them to me, a note saying what I’m thinking – or give them a call and say, “Hey, this is what I’m thinking. I think they need this type of big surgery or radiation,” so that they know. Once the surgery is done, I usually that night, when I finish the surgery, give them a call or give their office a call and say, “Hey, we’ve just finished Mr. X’s surgery. This is what we did. I expect him to stay about seven days in the hospital, and you might be hearing from him about a drain removal.” Or, if it’s something smaller, saying, “We’re going to send him home tonight. Would you mind taking out the drain in four or five days to make sure that everything – and doing a quick wound check.”
  
  And we work together really well here. It’s not like that everywhere. Other places that I’ve been don’t have such a great relationship with the outside referring people as we do, but we are lucky that the people in Alabama and the surrounding areas are very, very helpful and very, very friendly. We work together as a team, not as competing entities, and so it’s really nice to be able to talk with these guys, get their ideas, and make sure that they’re okay with what we’re doing, how we’re doing it, and involving them in the aftercare so that they can not only see the patients for us afterwards but also help out as they can so that the patients don’t have to make a six-hour trip to have a five minute appointment to get a drain removed and things like that. It helps when you keep the referring doctors updated in the care.
  
  Melanie: Thank you so much, all of you, for being with us today. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician.
  
  
  
• Hosts:Melanie Cole, MS