JOSE FRANCISCO GALLEGOS HERNANDEZ Hospital de Oncología, CMN SXXI. IMSS México City.

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1 JOSE FRANCISCO GALLEGOS HERNANDEZ Hospital de Oncología, CMN SXXI. IMSS México City.

2 HNSCC with a global incidence of over 500,000 cases and 200,000 deaths annually is the leading cause of mortality and disability. It affects people in the productive age-group Most of this mortality/morbidity is preventable

3 LIFE STYLE TOBACCO-ALCOHOL MICRO-ORGANISMS SEXUALS HABITS H&N CANCER INMUNOLOGICAL CHEMICAL GENETIC GENETICS PHYSICAL

4 H&N CANCER IN MEXICO In Mexico it is estimated that cancer of the head & neck is 13th in all neoplasms. There is lack of uptake by the tumor registration system. The three most frequent neoplasms are: oral cancer, laryngeal cancer and or pharyngeal cancer

5 H & N CANCER IN HOSPITAL DE ONCOLOGIA Each year, hospital de Oncología, diagnoses and treats 2,400 people with H&N cancer, of all locations (10 new cases/day) At least 60% of patients have loco-regionally advanced stages in our environment

6 KEY POINTS Many cancers of the head and neck can be cured, especially if they are found early. Treatment varies according to the type, location, and extent of the cancer, and often includes a combination of surgery, radiation therapy, and chemotherapy. Surgery is the primary treatment for most cancers of the head and neck.

7 Patients suffering from head and neck malignancies must be treated but always regarding the consequences of surgery specifically loss of function and physical deformity. ONCOLOGICAL CONTROL Function

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9 The initial and standard treatment of oral cancer is surgery, allows proper staging and control of the disease 1) PRIMARY TUMOR 2) CERVICAL NODES 3) RECONSTRUCTION

10 PRIMARY TUMOR RESECTION Surgical margins Adequate relationship between: Function-Extension QUOL

11 NECK DISSECTION 1. N + Comprehensive neck dissection 2. N0 Supraomohyoid ND(I-III) Exceptions: Tumors <5mm thick Candidates to SNB

12 FASCIAL NECK DISSECTION Patients c-usn0 with SCC of tongue and flour of the mouth Afferent lymphatic SN

13 Trans-mandibular buccopharingectomy Fibular free-flap

14 INITIAL STAGES 1) Trans-oral surgery Laser Robot-assisted 2) Radiotherapy 3) Open conservative surgery 1) Epiglotectomy 2) Cordectomy 3) Fronto-lateral laryngectomy LOCO-REGIONAL ADVANCED 1. TOTAL LARYNGECTOMY 2. SURGICAL CONSERVATIVE PROCEDURES 3. NON-SURGICAL ORGAN- PRESERVATION

15 Total laryngectomy indications 1Loss of function 1Extra-laryngeal extension (T4A-B) 1Airway obstruction 1Subglottic tumor extension

16 INDICATIONS 1. ABSENCE OF SUBGLOTIC INVASION Surgical techniques a) Subtotal supracricoid laryngectomy with CHEP 2. ARITENOID MOBILITY 3. ADEQUATE VENTILATORY FUNCTION b) Supra-cricoid-Hemipharyngo-laryngectomy c) Horizontal supraglottic laryngectomy

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18 Gallegos etal Cir Cir

19 SYSTEMICALLY ASSOCIATED WITH NECK DISSECTION

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21 OROPHARYNGEAL CANCER HPV status is a predictor of oropharyngeal cancer prognosis. Patients with p16-positive oropharyngeal cancer had a better prognosis and fewer rates of adverse events, relative to patients with p16-negative disease. Patients with p16-negative disease had worse outcomes

22 OROPHARYNGEAL CANCER WHEN TO OPERATE? P-16 POSITIVE T1-2,N0-1(<3cm); Trans-oral resection and antero-lateral ND (N0) or comprehensive ND(N+) Depends on the site of the tumor and the morbidity associated with the procedure P-16 NEGATIVE T1-2,N0. Trans-oral resection AND at least antero-lateral neck dissection (I-IV) Probably the sites with the highest probability of resection are lateral wall, tonsil and T1 of the base of the tongue

23 NECK DISSECTION IMPORTANCE IT IS THE ONLY PROCEDURE THAT ALLOWS US ADEQUATE STAGING AND ONCOLOGICAL CONTROL IT ALLOWS US TO SELECTING PATIENTS CANDIDATES TO FOLLOW-UP RADIOTHERAPY CHEMO-RADIOTHERAPY TYPES 1. SOHND = cn0 oral cavity 2. LATERAL ND = cn0 Orophar 3. ANTERO-LATERAL ND = cn0 oral cavity/orophar 4. Comprehensive ND = cn+

24 IN MOST PATIENTS WITH NODE METASTASIS (cn+); INITIAL SURGERY, WHEN THIS IS POSSIBLE; OFFERS BETTER CONTROL.

25 UP-FRONT NECK DISSECTION Part of the data suggest advantages toward less surgical complications compared with salvage ND, decreased serious acute radiation toxicity and better oncological outcomes when compared with (C)RT alone. The role of ND before (C)RT, called up-front neck dissection is not clearly established. Elicin O etal. Up-front ND followed by definitive Ch-RT in SCCHN. Rationale, complications toxicity rates, oncological outcomes. Systematic review.radiother Oncol 2016

26 SKULL BASE TUMORS

27 Anterior cranio-facial resection allows us complete resection, adequate control and minimal morbidity

28 WHEN NOT TO OPERATE Anatomic factors Brain Eloquent part of cortex Superior sagittal sinus Cavernous sinus Tumor Factors Patient factors Medical Fitness Patient commitment

29 In head and neck surgery, issues of appearance, identity, function, and communication are the foremost considerations when we decide when, and whether, to operate. Knowing when to operate is the sine qua non of the wise surgeon. But the inverse (WHEN NOT TO OPERATE) is also true.

30 TAKE HOME MESSAGES 1. The first treatment is essential in outcome of patients with H&N cancer 2. The treatment must be multidisciplinary 3. An essential part of the treatment is to maintain an adequate balance between control/morbidity/sequelae