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Patients at The Johns Hopkins Head and Neck Cancer Center benefit from access to top experts in all areas of cancer treatment. This includes specialists in head and neck surgery, medical oncology, radiation oncology, reconstructive surgery, pathology, rehabilitation, radiology, neurology and oral surgery.
Different cancer treatments have varying effects on patients’ quality of life. At Johns Hopkins, our physicians are committed to preserving quality of life while maximizing efforts to defeat cancer. Physicians routinely collect information regarding all facets of quality of life for head and neck cancer patients, including speech, swallowing and social functioning, and will invite you to participate in our studies to help our understanding of how cancer therapies affect daily living activities.
Radiation therapy is often a part of standard treatment for head or neck cancer patients. It can cause problems such as infection to the gums, mouth sores and tooth decay. For this reason, it is important for you to visit your dentist and to have any needed dental treatment completed PRIOR to starting radiation treatment at The Johns Hopkins Kimmel Cancer Center. Dental treatment AFTER radiation treatment can be complicated by slow healing and the risk of infection.
Importance of Seeing a Dentist Prior to Radiation Treatment for Head and Neck Cancer
Radiation treatment used during your cancer care can harm normal cells including cells in your mouth. If you go to the dentist before head and neck radiation treatment begins, you can help prevent serious mouth problems from developming after or during your radiation treatment. Side effects of radiation treatment often happen to a patient because their mouth is not healthy before the radiation treatment begins.
Intensity-Modulated Radiation Therapy (IMRT)
IMRT is an advanced method of radiation therapy that ‘modulates’ (or is able to vary the intensity) of the dose of radiation to the tumor while minimizing the dose to the surrounding normal structures. This is achieved through computer-controlled machines and multiple beams of radiation from different angles. The radiation beams shape can change during treatment, bending around healthy tissues to target just the cancerous tissue. The result is a ‘cloud’ of radiation that is designed to conform to the three-dimensional shape of the tumor while reducing the radiation dose to the surrounding normal parts of the head and neck. This helps to reduce the risk of side-effects which can show up during treatment and also helps to reduce the risk of developing injury to important functions such as saliva production and swallowing.
The radiation planning process involves the correct identification of the anatomical location of the tumor and the normal structures in the patient. Physicians use diagnostic imaging tools including computed tomography (CT), positron emission tomography (PET) and magnetic resonance imaging (MRI) in addition to physical findings. The radiation therapy is typically administered in a series of daily appointments (Monday through Friday) over five to seven weeks. In order to increase treatment precision, the patient is immobilized with the help of a custom fitted mask. The mask is made during the radiation “planning session” and is molded to fit the individual patient. The mask is made of a thermoplastic material which is soft when heated and becomes rigid when it cools.
Neoadjuvant chemotherapy ( Chemotherapy ONLY, given prior to Radiation or Surgery )
Neoadjuvant (or induction ) chemotherapy is a drug treatment given to cancer patients before radiation or surgery. The aim is to reduce the size of the tumor and decrease distant metastasis, hoping to improve the success of additional treatments. At Johns Hopkins, a combination of cisplatin, docetaxal and 5 FU (Fuorouracil ) is used primarily for patients with bulky, locally advanced squamous cell cancers of the head and neck. These tumors are typically found in the mouth, tonsils, base of the tongue, hypopharynx, and larynx. In certain patients with undifferentiated sinonasal cancers (rare cancers of the nasal cavity or sinuses) and esthesioneuroblastomas (a rare cancer of the upper nasal cavity), a combination of cisplatin and etoposide is used.
Current clinical trials studying the use of induction chemotherapy includes a combination of afatinib, carboplatin and paclitaxel followed by concurrent chemotherapy and radiation.
Concurrent chemoradiation (Chemotherapy and Radiation together)
Concurrent chemoradiation is the administration of a drug during radiation therapy. At Johns Hopkins, this treatment is considered the standard of care in the following circumstances:
- For localized squamous cell carcinomas (those that have not spread beyond the sinuses, mouth, throat, and the neck) that cannot be completely removed with surgery. This is termed unresectable cancer.
- For patients who have had their cancer completely removed by surgery but are at high risk for recurrence of the cancer – in this situation, surgery is followed by chemoradiation.
- For patients with locally advanced larynx cancer (cancer of the voicebox that has spread to nearby tissue or lymph nodes) that would necessitate removal of the larynx – in this situation, chemoradiation may be appropriate to try to preserve the patient’s natural voice; surgery is then reserved for recurrence of the cancer in the larynx or if the cancer is not completely eradicated by chemoradiation.
- For certain patients with cancers of the oropharynx (ex. tonsil, tongue) – chemoradiation instead of surgery may be appropriate to preserve speech/swallowing abilities.
In addition, Johns Hopkins offers several clinical trials to improve upon current chemoradiation therapy for patients with head and neck squamous cell carcinoma. You will be invited to participate in these trials if you are eligible.
- The addition of tadalafil to improve the immune function during chemoradiation.
- The addition of the HPV (human papilloma virus) vaccine after completion of chemoradiation.
- Radiation de-intensification to decrease treatment related toxicities for patients with HPV related cancers.
- Treatment intensification by adding dasatinib and cetuximab to the chemoradiation.
Whenever possible, oncology surgeons at Johns Hopkins aim to use minimally invasive surgical techniques to best preserve patients’ function and appearance. Small tumors sometimes can be removed during outpatient surgeries under local or general anesthesia. If the cancer is larger, a patient most likely would need to stay in the hospital following surgery. Your physicians will discuss the best type of operation for you, depending on the size and location of your cancer, and whether it has spread.
Listed below are some procedures Johns Hopkins surgeons are using to remove tumors. Because of the high volume of complex cancers being treated at our medical center, our surgeons have extensive experience in performing these procedures.
Transoral Endoscopic Surgery
Many patients with smaller tumors in the mouth, throat and voice box may be candidates for tumor removal through the mouth (transoral). This is a minimally invasive technique that avoids incisions through the neck or face. These procedures result in less swelling, less scarring and a lower risk of infection. It also helps preserve function and appearance. Patients may be able to eat right after surgery, and even if their voice is affected it may be still be functional.
Our team has much experience in transoral surgery using both the laser and the surgical robot (transoral robotic surgery or TORS). Johns Hopkins was the first center in Maryland to begin TORS and remains a leader in this area.
Neck Dissection with Nerve Preservation
Neck dissection operations take out lymph nodes, that may have cancer, on one or both sides of the neck through an incision in the neck. Traditionally, surgeons have removed tissue from five areas or levels in the neck, sometimes resulting in significant impairment to shoulder function and producing accompanying pain and numbness. With advances in the field, there are now several types of neck dissections, varying based on what structures are affected by cancer and need to be removed.
Johns Hopkins surgeons, when possible, now perform modified or selective neck dissection procedures. Whenever possible the involved lymph nodes are removed, sparing the sternocleidomastoid muscle (a long muscle in the neck that rotates the neck and flexes the head), the spinal accessory nerve (a nerve that carries messages from the central nervous system to two major neck muscles) and the internal jugular vein (a major blood vessel that drains blood from the head, brain, face and neck and sends it toward the heart).
In the selective procedures, surgeons operate on fewer areas, preserving function in the shoulder, and can sometimes leave the sensory nerves, preventing numbness, especially in the earlobe.
Most procedures must be done on an inpatient basis, with patients staying in the hospital for one night. In some cases, patients may go home the same day.
Transoral Robotic Surgery (TORS)
Surgery is one option for treating oropharynx tumors – cancers occurring in the throat, base of the tongue, and tonsils. Conventionally, removing tumors through surgery required a very large neck incision and cutting of the bottom jaw. This left patients with difficulty in swallowing and speaking. Today, advances in surgical equipment have made it possible to reach orophayrngeal tumors through incisions in the mouth by using robotic technology.
Patients that may benefit most from robotic procedures include those with early stage tumors with little or no lymph node involvement in the neck. Approximately 10 to 20 percent of patients with oropharygeal tumors may be considered ideal candidates for the procedure. Patients who smoke tobacco or have HPV negative tumors are especially encouraged to receive a primary surgical treatment for their cancer as these cancers often do not respond as well to radiation and chemotherapy.
What are the Benefits?
Studies have shown that the outcomes of such procedures – called transoral robotic surgery – result in swallowing and speech function that is as good or better than other surgical methods, but without disfiguring scars. While up to 20 percent of patients who receive combination chemotherapy and radiation may have feeding tubes inserted for an average of five years, zero to 5 percent of patients undergoing transoral procedure need the tubes during the same time.
For physicians performing TORS, a guided endoscope helps create a high resolution, 3D image of the back of the mouth and throat, typically a difficult area to reach with conventional tools. With two robotically-guided instruments that act as a surgeon’s arms, tumors are able to be dissected free from surrounding tissue safely.
Pairing Surgery with Radiation
Most patients undergoing TORS for oropharyngeal cancer still need to receive radiation therapy. But since the tumor has been surgically removed, radiation doses are generally lower than for patients who receive combined chemotherapy and radiation regimens.
Ongoing Surgical Research at Johns Hopkins
Johns Hopkins surgeons are monitoring patients who receive TORS for oropharyngeal cancer with pre- and post-operative tests on swallowing, speech and quality of life. The results may help surgeons compare the outcomes of robotic procedures with more conventional ones.
Surgeons at Johns Hopkins are working with computer and bioengineering experts at the Johns Hopkins University to develop a robotic tool to improve surgeons’ access to the larynx (voice box). Head and neck cancer physicians generally use a flexible scope called a laryngoscope to access the voice box and other areas of the throat. Johns Hopkins experts are developing a robotic laryngoscope that can be used by thumbing a joystick with one hand. By threading a laser fiber optic line through the device, surgeons can remove tumors without using a scalpel in otherwise unreachable areas. They believe that such a device can also provide improved high resolution images of the throat, dexterity around corners, and required stability to use in operating room settings.
Scarless Surgery for Thyroid Tumors
To avoid a disfiguring scar across the neck from thyroid surgery, patients are turning to Johns Hopkins surgeons who are testing new techniques to remove the endocrine gland without a neck scar.
Young, healthy patients with select benign or suspicious lesions in the thyroid could be considered candidates for the procedures. Approximately half of all thyroid surgeries are done for benign or suspicious lesions. Patients with known cancers must undergo surgery via the neck because surgeons need to remove both sides of the thyroid gland and dissect lymph node tissue surrounding it.
In one procedure that was first developed in South Korea, surgeons enter through the axilla (or armpit) and use robotic arms extended under the chest to access the thyroid. Doctors say there a similar risk profile with this procedure, and patients retain good speech and swallowing ability.
Johns Hopkins surgeons will be monitoring outcomes of patients treated with the procedure. They are also studying the feasibility of removing the thyroid gland through the bottom of the mouth with robotic devices.