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Speaker: Dr David Vokes

Introduction

Dealing with head and neck cancer is about optimising function.

There are three types of dysfunction:

  • Preexisting eg stroke
  • Disease-related. Cancer can destroy tissue, eg vocal chords, bone
  • Treatment - surgery, rads and chemo can lead to dysfunction eg swallowing problems

How to prevent dysfunction:

  • Prevention is best through behaviour modification, eg smoking, drinking cessation or by use of HPV vaccinations for OPC cancer
  • Early detection through patient and physician education, eg doctors need to know that if patient has voice dysfunction for more than 3 weeks they need to be seen, especially if there is history of smoking. Doctors not given much education on this cancer, 3 - 4 hours in medical training. 
  • Careful treatment selection: Minimally invasive surgery, balancing act to get adequate margins plus rehabilitation and reconstruction

Avoiding long term dysfunction by careful use of the three treatment modalities: surgery, radiation and chemo

Radiotherapy

  • Omit and use surgery
  • Reduce dose and use surgery 
  • Use targeted radiotherapy like the IMRT we have had for the last decade, avoiding important structures (10 years ago radiotherapy was not very discriminatory. More like an atom bomb than cruise missile)

Chemotherapy

  • Omit - use surgery instead. It intensifies the side effects of radiotherapy.
  • Minimise it. Avoid triple modality if possible. However, if the cancer has broken out of the lymph nodes as with “extracapsular spread”, the triple modality does have a significant survival advantage.

Surgical techniques

The KTP laser

A KTP laser is a solid-state laser that uses a potassium titanyl phosphate (KTP) crystal as its frequencing doubling device.

This laser differs from the “cutting” laser of previous decades: the CO2 Laser. It ablates layers of tissue. “You keep on going down to get rid of the cancer.”

It’s one treatment and it takes the patient 6 weeks to heal. Minimally invasive.

Indicated for

  • Dysplasia - precancerous, abnormal cells
  • Carcinoma in Situ - a static early tumour
  • Squamous cell carcinoma - you need exposure. Need to be able to reach the tumour.

It is useful for laryngeal cancer in early stages not so much for other head and neck cancers. Avoids the need for a total laryngectomy. Has been in use since 2010. Excellent results.

(Another way of saving the larynx is to use a flap. One patient had a second primary and had already had radiotherapy, could not have it again so was given a gastrointestinal flap, pulled up from the gut. This is called a dynamic flap and still contains muscles that can move.)

Transoral Robotic Surgery (TORS)

https://biomedical.closeupengineering.it/en/da-vinci-leonardo-minimally-invasive-surgical-robot/6724/

Head and neck cancer is increasing in younger patients with the epidemic of tonsil and base of tongue cancer caused by the HPV virus. Traditional surgery was very morbid (caused a lot of dysfunction).

Southern Cross Hospital, North Harbour, has a a da Vinci robot for this surgery. David and his colleagues are putting forward a business case for one in the public hospital. (Does anyone have three million dollars? Diana said that we would help fundraise!)

Traditional surgical techniques are difficult for base of tongue cancer. Using the da Vinci robot, the surgeons feel as if they have been shrunk and are in the patient. They use an endoscope and the camera goes inside the patient. The robot has graspers on what look like human wrists but are more flexible. David and his colleague, Dr John Chaplin have done five cases since August and only one of them required radiotherapy.

Neck dissections are done beforehand then allowed to heal.

The robot was FDA approved in 2000 but head and neck cancer has been a latecomer in robotic surgery.

New Zealand is not behind most of the rest of world but Australia has many more TORS units.

Here is a photo of TORS surgery found on the Twitter feed of @throatsurgeon in Australia. David had photos but I was not quick enough to snap them. It really is extraordinary surgery.

David and his colleague trained in Atlanta and Pennsylvania. Part of their training involved playing games to become familiar with the instruments.

Total laryngectomy

David spoke about the side effects and the rehabilitation when a patient needs a total laryngectomy.

Laryngectomees suffer many issues with the following as well as learning to speak again. These include loss of smell, taste, ability to swim and many more.

Rehabilitation is helped by:

  • Pre-op preparation and reassurance
  • Multi Disciplinary team essential
  • See a veteran laryngectomee

Speech rehabilitation involves:

  • Electrolarynx
  • Tracheoesophageal speech using a valve in the throat. Most efficient.
  • Oesophageal - difficult - swallowing air. One member said that in a group of Japanese laryngectomees he met, all used esophageal speech 
  • Writing
  • Mouthing 
  • Gestures
  • Speech software

Some other points

  • Stoma stenosis or scarring, closing up the stoma can occur after rads
  • Important to look after lungs
  • Resuscitation through throat is needed. Patients should wear a bracelet to show they are neck breathers. 
  • Psychological rehabilitation is needed

David showed us a painting by a patient made years ago - like Edward Munch's The Scream - showed the grief anger and confusion. It must have been very therapeutic to get these feelings onto canvas and would have given other patients a feeling of recognition.

Help and information can be found in Itzhak Dribook’s blog and his book. He is a pediatrician who is also a laryngectomee. http://dribrook.blogspot.co.nz/

Thank you David for your talk. It was technical but informative and it’s reassuring that our people have such committed surgeons who want to maximise the quality of life of their patients.

And a tribute to our many members who are laryngectomees and have taught us so much about how to respond to such a profound change in their lives.

This summary was written by a layperson. If anything is incorrect, please let me know. 

Email me when people comment –

Maureen Jansen, secretary of HNCSSN, amateur investigator of head and neck cancer issues. Always willing to be questioned and challenged.

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Comments

  • Thank you so much Maureen. I have learned a lot by you well written and informative article on the October meeting. The way you have explained it has made it easier for me to understand. Thank you for your dedication.
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