Mr Stefano Stea | London | Head & Neck Cancer
This surgical speciality has a leading role in the management of orofacial cancer and head & neck cancers in general, with close relationships to other specialities, in particular oncology and radiotherapy.
Orofacial cancer is a serious malignant disease, which is fatal if not treated, and in the oral cavity usually begins as a rough patch, ulcer or lump affecting the lip, tongue and floor of mouth with a significant tendency to metastasise to the cervical lymph nodes.
Over 2,000 new cases are reported each year in the United Kingdom, with a 5-year death rate of approximately 50%. This is similar to the death rate for other cancers, such as breast cancer, but shows a worsening trend in the last decade against, for example, carcinoma of the cervix where early diagnosis, due to a national screening programme, has improved the prognosis for many patients.
Targeted screening of high risk groups within the population, ie. heavy smokers and drinkers, could improve the situation but at present do not exist in the United Kingdom. Screening of low risk groups and regular dental patients will probably not have any impact on referral patterns. It remains a fact that over 50% of cancers affecting the oral cavity and head and neck region present as advanced stage disease, with relatively poor outcome of treatment compared with Stage I presentations.
A significant number of oral cancers go through a pre-malignant state before becoming invasive cancers. These potentially malignant lesions are clinically white or red / speckled oral mucosal lesions (leukoplakia / erythroplakia). These lesions are curable if excised (either by surgery or laser surgery) and the risk factors controlled. Some pre-malignant lesions can be managed by regular review, with or without medical treatment.
There is now a requirement of all medical & dental practitioners who suspect a patient of having malignant disease to refer that patient to be seen by an appropriate specialist within 14 days. There is, therefore, no role in general practice to investigate suspicious lesions in the oral cavity either by vital staining, biopsy or other investigations. All these patients should be referred to an oral and maxillofacial surgeon specialising in malignant disease of the head and neck.
What should a patient look for?
Please remember that mouth cancer is still quite rare. Most mouth problems are nothing to worry about but do not delay seeking professional help. See your dentist or doctor who will be able to refer you to a specialist clinic to see an oral and maxillofacial surgeon.
Signs and symptoms to look for include a non-healing sore or ulcer of more than 2 weeks duration, warty lumps or nodules in the mouth, white or speckled patches which may bleed, thickening of the skin in the mouth, difficulties with speech, swallowing or mouth opening and any lump in the neck. Pain is not usually present in the early stages of mouth cancer.
The problem is much more common if you smoke or chew tobacco, especially if you drink alcohol as well.
Patients with orofacial cancer should be referred to the multi-disciplinary team (MDT) dealing with head and neck cancer. Such teams are becoming centralised in cancer centres, with satellite clinics in cancer units. The broad spectrum of specialities involved in the management of head and neck cancer, and their support services, requires a large and complex team approach.
Radiotherapists and oncologists will have patients whose lesions are treatable with primary radiotherapy. Most of these lesions will be small and accessible, but others are those extensive presentations where surgical resection is considered impossible and where the outcome is likely to be very poor.
A majority of patients require tumour resection, defect reconstruction and subsequent rehabilitation to enable the patient's return to society. Depending on the findings at the time of the surgical resection, a proportion of these patients will also require post-operative radiotherapy treatment.
The role of free tissue transfer has revolutionised the surgical options in reconstruction of ablative cancer resections (and also traumatic defects and some congenital deformity syndromes). The surgical challenge in the reconstruction of the face and jaws uniquely involves the restoration of the facial skeleton as well as the soft tissues of the face and mouth. For example, tissue to replace the tongue can never fulfil the functions of speech, taste and swallowing, which are so important to a patient's quality of life. Stereolithography has recently added a new dimension in the planning of complex facial and orbital defects.
Maxillofacial reconstructive techniques are not as yet able to restore the function of tissues that are replaced with the exception of the mandible. For example, tissue to replace the tongue can never fulfil the functions of speech, taste and swallowing so important to a patient's quality of life. Although it is technically possible to transplant a tongue with its nerve and blood supply, further research will have to be carried out to assess the success of such techniques. On the other hand, we can replace the structure and function of the mandible by transferring bone and soft tissue and then placing osseo-integrated implants to which a prosthetic appliance can be attached to restore the function of chewing as well as restore a patient's appearance and smile.
Use oh the soft tissue component of the radial forearm flap is now the favoured method of reconstructing the soft tissues of the mouth and pharynx. This flap can be made sensate by incorporating the antebrachial nerve of the forearm and anastamosing this nerve to a donor nerve in the oral region. The improved sensation can help initiate the swallow reflex and improve overall oral function. Reconstruction of the mandible is necessary in about 30% of oral cancer resections. Techniques include the use of the fibula, iliac crest and scapula flaps and, in selected cases, the immediate placement of implants in the grafted bone enables rapid rehabilitation of oral function.
Maxillectomy damage, which may be so extensive as to include removal of the eye, may be treated by obturation with a prosthesis to fill the large damaged area which communicates between the eye socket and the oral cavity. A combination of intraoral and extraoral implants (for example in the supraorbital rim) offer considerable advantages in these situations.
However, the restoration of the excised bone and soft tissues with a vascularised graft from the iliac crest, incorporating one of the muscles that lie in the abdominal wall, may be a better option for many patients. This allows the patient to wear a denture which can be supported by implants in the reconstructed maxilla and the eye can be restored with a separate implant-retained orbital prosthesis.
The psychological suffering associated with facial disfigurement and oral dysfunction is a considerable burden to many patients, and range from facial scarring and port wine stains to severe maxillofacial injury or extensive resection for head and neck cancer. These patients require practical and psychological help in their struggle to restore their lives and the multi-disciplinary team approach, involving speech therapists, dieticians, nurse liaison support and palliative care, and care in the community, all play a vital role. Any surgical intervention in the treatment of orofacial disease involves a multi-disciplinary team approach.