Treatment

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. They meet weekly to review patient’s records to determine the best treatment plan.

Treatments – recommended based on the location, size and type of cancer – may include surgery, radiation and/or chemotherapy. Any recommended reconstructive techniques are planned before treatment begins to optimize restoration of the patient’s face, and speech and swallowing abilities. Speech language pathologists also are involved in every step of patient care to maximize speech and swallowing function.

Quality of Life

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. For example, initial research directed by Dr. Christine Gourin has found that some patients with advanced tumors undergoing non-operative treatments and selected patients undergoing surgical treatment can maximize their quality of life by receiving aggressive swallowing therapy throughout their treatment.

Radiation Therapy
Intensity-Modulated Radiation Therapy (IMRT)

IMRT is an advanced method of radiation therapy that ‘modulates’ the dose of radiation to the tumor (‘target’) while minimizing the dose to the surrounding normal structures. This is achieved throughout computer-controlled machines and multiple beams of radiation from different angles: the beams shape can change during treatment, bending around healthy tissues to target just the cancerous tissue. The resulting ‘cloud’ of radiation is designed to conform to the three-dimensional shape of a target. The planning preliminarily involves the correct identification of the anatomical location of the target 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.  This therapy is typically administered in a series of daily appointments over five to seven weeks.  In order to increase treatment precision, the patient is immobilized with the help of a thermoplastic mask.

Chemotherapy
Neoadjuvant chemotherapy

Neoadjuvant chemotherapy is a drug treatment given to cancer patients before radiation or surgery, with the aim of reducing the size of the tumor, hoping to improve the success of additional treatments. At Johns Hopkins, a combination of Cisplatin, Taxotere, and Fuorouracil (5-FU) is used primarily for patients with bulky, locally advanced squamous cell cancers of the head and neck, like the 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 include one for patients with locally advanced head and neck cancers that will investigate the novel combination of Cetuximab, an EGFR monoclonal antibody, with Dasatinib, a SRC inhibitor, followed by chemotherapy and radiation. 

Another clinical trial will investigate treatments for patients with head and neck squamous cell cancer of the oropharynx. The human papillomavirus (HPV) has been identified as a risk factor for these cancers; patients seem to have a better outcome with chemotherapy and radiation and overall have a better prognosis. Hopkins investigators plan to study this with neoadjuvant chemotherapy using Cetuximab, Cispaltin and Taxotere followed by lower-dose radiation with Cetuximab.

Concurrent chemoradiation

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 cancers (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.

Surgery

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 position 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, surgeons have an extensive skill in performing these procedures.

Laser Surgery

A recent technique for some patients with cancers of the larynx (voicebox) is transoral laser surgery. Rather than make an incision from outside the body, an endoscope (lighted viewing tube) is placed into the mouth to access the cancer from inside the body. Then surgeons aim a carbon dioxide laser at the cancer. The laser energy cuts into the tumor, sealing blood vessels as it works to limit bleeding. Physicians cut the tumor into small pieces that are removed a little at a time, until the entire tumor is gone. Using the laser helps preserve neighboring healthy tissue and nerves.Laser surgeries can often be performed on an outpatient basis. The procedure results 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.In some cases, surgeons can use lasers to de-bulk tumors that are not responding to chemotherapy and radiation. This keeps the airway open so patients do not need a tracheotomy (a tube surgically implanted in the neck to bypass obstructions and allow air to get to the lungs) while waiting for definitive therapy.

Neck Dissection with Nerve Preservation

Neck dissection operations take out lymph nodes on one or both sides of the neck that may have cancer implants using 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. In one procedure, only portions of the neck are operated on. Another type of surgery removes tissue from all five levels, 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.

IGRT represents a further evolution of IMRT, meaning that the treatment session is delivered only after checking, on a daily basis and with the patient on the treatment table, the correct position of the target with respect to the machine. At Johns Hopkins this is done by acquiring a CT scan on the treatment table. A more precise treatment delivery implies fewer dose to the normal structures and a higher likelihood of treatment success.

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.

Dr. Jeremy Richmon discusses robotic surgery:

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Who Benefits?

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.