This review will provide a comprehensive overview of the current management of oropharyngeal cancer. The contemporary literature, as it relates to diagnosis and management, will be summarized and the existing limitations of our knowledge will be highlighted. Research questions which need to be addressed as a matter of urgency will be listed and ongoing clinical trials designed to fill the current gaps in our knowledge will be briefly described.
Laryngeal cancer remains one of the most common airway cancers. Although the incidence has generally declined, the overall survival has actually decreased over the last 40 years despite advancements in its treatment. Treating a malignancy in this region is challenging, and management involves a balance between primary oncological control, organ and functional preservation, and minimizing treatment morbidity. Patients with laryngeal cancer require a truly multidisciplinary team approach. Surgery remains an integral part of management, with several viable organ preservation-based surgical approaches evolving over recent years. There have also been significant advancements in other nonsurgical laryngeal preservation treatment modalities, such as radiation and chemotherapy. However, there still remains a need for further research in understanding the disease, and more innovation in its treatment. Future research in the treatment of laryngeal cancer should be focused on strategies to improve locoregional control and overall survival, while reducing patient morbidity and the impact on quality of life.
One of the most important prognostic factors in head and neck cancer is the presence or absence, level, and size of metastatic neck disease.
Controversies in neck management still exist due to the paucity of quality clinical trials with most evidence extrapolated from retrospective studies. However, recent evidence has emerged to address some of these areas including the ideal management of the N0 neck, the role of sentinel node biopsy in occult neck disease, posttreatment surveillance with positron emission tomography and computed tomography (PET-CT) and incorporation of P16 status and extranodal extension (ENE) in the recent 8th edition of AJCC in nodal staging.
This paper provides an update on the current management of metastatic neck disease in the setting of squamous cancers arising from the upper aerodigestive tract.
Cervical lymph node status is a significant prognostic factor for all patients with head and neck cancer. There is still ongoing deliberation on the extent of surgical therapy to offer patients, particularly those who have a clinically negative (cN0) neck. Currently, preoperative examination and investigation [routinely ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI)] are utilized for treatment planning and the extent of surgery based on evidence of metastatic spread or perceived risk of occult metastasis.
It has been shown that that sentinel node biopsy (SNB) is a reliable staging test to detect occult metastases in early oral carcinoma, and its routine use has been advocated in the UK by the National Institute of Health and Clinical Excellence (NICE). Sentinel node biopsy can be used in most solid tumors that spread via lymphatics but its application to extraoral head and neck malignancies (other than primary skin tumors) has not been widely reported. In this article, we review the potential application of SNB in new areas of the head and neck.
Head and neck squamous cell carcinoma (HNSCC) is the 6th most common cancer globally, originating from the epithelial surface of the upper aerodigestive tract from the lips to the larynx. It commonly presents with locally advanced disease, with a recurrence rate of around 50% despite aggressive multimodality treatment involving surgery, radiotherapy and chemotherapy or EGFR inhibition as appropriate. Improvements in understanding the underlying cancer biology and its evolution within the complex interactions of the tumor microenvironment, there is gathering interest in and evidence for the use of immunomodulating agents in the management of HNSCC. Immune checkpoint inhibitors, primarily programmed cell death protein 1 (PD-1) inhibitors to date, which inhibit the inhibitory interaction between PD-1 and its ligand PD-L1, have demonstrated durable improvements in patient outcomes in advanced/metastatic HNSCC, with both nivolumab and pembrolizumab being granted FDA approval in 2016.
There are numerous clinical trials ongoing exploring the role of checkpoint inhibitors both as single agents and in combination, administered with established modalities such as chemotherapy and radiotherapy, as well as alongside other novel immune modulators. These trials are not limited to advanced/ metastatic HNSCC, but also explore neoadjuvant or adjuvant settings. As studies complete and more data become available, immunotherapy agents are likely to have expanding roles within the treatment algorithms of HNSCC, and with greater biomarker development have the potential to further improve patient outcomes via a personalized therapy approach.
Management of laryngeal dysplasia often poses a clinical conundrum, especially so with its unpredictable propensity for malignant transformation. The wide heterogeneity in published results and the dearth of level I evidence makes it challenging to arrive at a consensus or best practice guidelines. In 2010, ENT UK had developed such a guideline based on critical analysis of previously published data and professional opinion. This article examines the available evidence, and attempts to highlight the best possible modalities in investigation and management strategies as objectively as possible.
DOI: 10.5005/jp-journals-10001-1342 |
Open Access |
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Butterworth CJ. Immediately Loaded Zygomatic Implant Retained Maxillary Obturator used in the Management of a Patient following Total Maxillectomy. Int J Head Neck Surg 2018; 9 (2):94-100.
Aim: This study aimed to report on the use of specialized zygomatic oncology osseointegrated implants to assist in the management of a patient struggling to cope with a large maxillary obturator prosthesis following a low-level total maxillectomy.
Background: Maxillary obturator prostheses are commonly used in the rehabilitation of patients following maxillary resection. Whilst these prostheses can be retained adequately with remaining maxillary teeth and/or implants, as the horizontal component of the resection increases, the retention, and support of the obturator are increasingly difficult to manage.
Case description: A 72-year-old female patient was referred with problems tolerating a large removable maxillary obturator prosthesis, following total maxillectomy three years previously. Despite successful disease control without the need for adjuvant therapy, the patient functioned poorly with the obturator prosthesis which was poorly retained and supported by the large defect. In addition, the movement of the obturator resulted in soreness and ulceration, and she relied on the heavy use of denture fixative to assist in the wearing of the obturator prosthesis. Following a radiographic investigation, four zygomatic oncology osseointegrated implants were placed into the residual zygomatic bodies and within a week were used to provide much-improved support and retention for the large obturator prosthesis, resulting in successful amelioration of the patient's pre-existing difficulties.
Conclusion: The use of specialized remotely-anchored osseointegrated zygomatic implants can provide a means of effective support and retention for large prosthetic obturators even where the horizontal component of the maxillary resection is large. The density of the zygomatic bone provides excellent initial stability for these implants which can be used immediately to support
Clinical significance: The use of zygomatic oncology implants provides an improved means of retaining and supporting maxillary obturator prostheses where these are required following partial or total maxillary resection.