General principles and outline of management
History & Clinical Examination :
• Clinical Staging
• Assessment of Performance and Nutrition Status.
• Investigations for histological diagnosis- Biopsy / FNAC / Slide Review
Goals of Treatment:
Stage I-IVA : Curative
Stage IV B-C : Palliative
Surgery and radiotherapy are the definitive therapies in the treatment of head and neck squamous cell carcinomas. Chemotherapy by itself is not a definitive treatment.
• It is used as a single modality in early disease (stage I & II).
• It is combined with post-operative adjuvant radiotherapy in advanced disease (stage III & IV).
• Wide excision of tumor in all dimensions with adequate margins and appropriate neck dissection is essential in local-regional control of disease.
• External beam radiotherapy and / or brachytherapy are used either as single modality or as a part of multi-modality treatment.
• Three Dimensional Conformal Radiotherapy (3-DCRT) Intensity Modulated Radiation Therapy (IMRT) or Image Guided radiotherapy ( IGRT) are useful advances in radiotherapy techniques that can be used in primary treatment with radiation therapy . These techniques allow for better sparing of adjacent critical structures like the spinal cord, parotids thereby enabling better tumor coverage and may help in dose escalation to the target volume.
It is usually used in combination with radiotherapy (sequential or concurrent. Current evidence favors concurrent administration of chemo radiotherapy). It has a role in organ/ voice preservation (in laryngeal / hypo pharyngeal cancers) and in oropharyngeal cancers. In select patients chemotherapy can be used for palliating symptoms.
General guidelines for selecting a treatment modality:
• Stage I / II disease – Single modality (Surgery or RT)
• Stage III & IV disease – Combined modality
Surgery + Radiotherapy
Chemotherapy + radiotherapy
Surgery is preferred over radiotherapy as a single modality in
• Sites where surgery is not morbid (cosmetically and functionally)
• Lesions involving or close to bone – to prevent radionecrosis.
• Young patients – possibility of a subsequent second primary
• Sub mucous fibrosis
RT is preferred over surgery as a single modality, where
• Severe impairment of function / cosmesis with surgery, e.g. base tongue, glottis.
• Surgery is technically difficult with high morbidity and poor results e.g. nasopharyngeal carcinoma.
• Patient refuses surgery / high risk of surgery
Criteria of Unresectability :
Primary disease: Adequate surgical clearance is not achievable
• Extensive InfraTemporal Fossa involvement
• Extensive involvement of base skull.
• Extensive soft tissue disease: skin edema/ ulceration.