Cancer of the oral cavity, pharynx and larynx : evidence-based decision making

Written for residents and practitioners of otolaryngology, medical oncology, radiation oncology, and maxiollofacial surgery, this book provides the reader with a comprehensive, concise discussion of the best evidence available on which to base clinical decisions needed when managing patients with squamous cell carcinomas of the oral cavity, pharynx and larynx. Because of its accessible and practical format, this book is considerably different than other related titles on the market. Formatted with questions at the beginning of each chapter that are then answered with evidence and best practices available for each case, each chapter addresses situations the clinician is likely to face in the diagnostic evaluation and treatment of a patient with cancer of the head and neck.​ Most clinical decisions in the management of cancers of the head and neck region are based on the results of a few controlled, randomized clinical trial trials (Evidence Level I). However, most decision-making is based on the results of case-control studies (Evidence Level II), descriptive studies, reports of expert committees, or opinions of respected authorities (Evidence Level III). This information is scattered throughout the literature and often comingled with information about other topics. Therefore, there is a need for a publication in which the evidence pertinent to making decisions regarding a particular clinical problem is distilled from the literature and presented in a single concise, clinical, situation-driven source. __Cancer of the Oral Cavity, Pharynx and Larynx: Evidence-Based Decision Making__ is just such a resource. Dedication 6 Preface 8 Contents 10 Chapter 1: Evidence-Based Medicine 11 Evidence-Based Medicine 11 References 12 Chapter 2: Oral Cavity Cancer 13 Decisions in Clinical Evaluation 13 Clinical Situation 13 What Is the Best Method to Assess Mandibular Invasion? 13 Should the Patient Undergo Panendoscopy? 19 Should an Ultrasound, CT, or MRI Scan of the Neck Be Obtained? 20 Should the Patient Have an Ultrasound (US) of the Neck and US-Guided Fine-Needle Aspiration of Lymph Nodes? 21 Should a PET Scan or a PET/CT Be Obtained in This Patient? 22 Positron Emission Tomography 22 Decisions in Treatment 23 Clinical Situation 23 Decisions Regarding the Primary Tumor 23 Surgery vs. Radiation (Why Is Surgery the Best Treatment Modality?) 23 Resection Margins 24 How Wide a Margin of Normal Tissue Should Be Resected Around the Tumor? 24 Should Frozen Section Examination of the Margins Be Used Routinely? 25 What Are the Implications of Having Initially Positive Margins on Frozen Section? 25 Decisions Regarding the Neck 26 Observation: Can the Neck Be Observed and Treated Only If Metastases Become Apparent? 26 Sentinel Lymph Node Biopsy 27 Is it Feasible, Is It Effective, Is It Practical? 27 Selective vs. Modified Radical Neck Dissection 28 Why Is Selective Neck Dissection the Operation of Choice? 28 Should Lymph Nodes in Level IV Be Included Routinely? 28 Decisions Regarding Adjuvant Therapy 29 Postoperative Radiation 29 What Are the Indications Supported by Evidence? 29 What Is the Ideal Timing of Radiation? 30 What Is the Ideal Dose of Radiation? 30 Postoperative Chemotherapy and Radiation 31 What Are Indications Supported by Evidence? 31 References 31 Chapter 3: Oropharynx Cancer 37 Decisions in Clinical Evaluation 37 Clinical Situation 1 37 Should Oropharyngeal Carcinomas Be Tested for HPV? 37 How Should the Tumor Be Tested? 39 What Are Prognostic Implications of a Positive and Negative Result? 40 Are There Any Treatment Implications of an HPV-Positive or -Negative Result? 40 Are Smokers with OPC at Higher Risk of Failure? 41 Are There Behavioral Implications of a Positive HPV Testing? 42 Should the Patient Undergo an Initial Panendoscopy? 43 Should a CT or MRI Scan Be Obtained? 43 Decisions in Treatment 44 Decisions Regarding the Primary Tumor 44 Clinical Situation 2 44 Clinical Situation 3 44 Conventional “Open” Surgery 44 Radiation Therapy 46 Hyperfractionated/Accelerated Radiotherapy 47 Chemoradiation 47 Transoral Surgery 49 What Margins Are Required to Adequately Resect the Primary Cancer? 50 Does HPV Have Any Bearing on Outcome Following TORS in These Patients? 51 Decisions Regarding the Neck 52 References 55 Chapter 4: Cancer of the Nasopharynx 60 Decisions in Clinical Evaluation 60 Clinical Situation 60 What Is the Best Method to Assess Skull Base Involvement and Parameningeal Spread? 61 Should a PET Scan Be Routinely Ordered for All Stages of Disease? 62 Should Epstein–Barr Virus (EBV) or Human Papilloma Virus (HPV) Testing Be Considered? 63 Should a PE Tube Be Inserted to Manage the Middle-Ear Effusion? 64 Decisions in Treatment 65 Decisions Regarding the Primary Tumor 65 Is There a Role for Induction Chemotherapy Prior to Starting CRT in Stage III to IVB NPC? 66 Evaluation of the Response to Treatment 66 Decisions Regarding the Neck 67 What to Do When a Palpable Lymph Node Persists After Chemoradiation? 68 Recurrence at the Primary Site 69 Potential Novel Therapies 69 References 70 Chapter 5: Cancer of the Hypopharynx 73 Trinitia Y. Cannon and Keren Bartal 73 Decisions in Clinical Evaluation 73 Clinical Situation 73 What Is the Best Method to Assess the Extent of the Primary Tumor? 73 Should a CT or MRI Scan of the Neck Be Obtained? 74 Should a PET/CT Be Obtained? 74 Is a Direct Pharyngolaryngoscopy and Esophagoscopy Warranted? 75 Decisions in Treatment 76 Typical Clinical Situation 76 Is Transoral Resection a Viable Option for Hypopharynx Cancer? 76 Typical Clinical Situation 77 Decisions Regarding the Primary Tumor 77 Organ Preservation with Chemoradiation Therapy vs. Surgery? 77 What Is the Role for Accelerated or Other Modifications of Radiation Therapy? 80 What Is the Role of Surgery? 80 Decisions Regarding the Neck 81 What Lymph Node Levels Should Be Resected on the N0 Neck? 81 What Lymph Node Levels Should Be Resected in the N+ Neck? 82 When Should Lymph Node in Level IB and Level V Be Included? 82 Should Level IIB Be Resected? 83 When Should the Retropharyngeal and/or Paratracheal Nodes Be Included? 83 Decision Regarding Reconstruction 84 When Is Primary Closure an Option? 84 When Can a Regional Flap be Used for Reconstruction and What Are the Options? 84 When Should a Free Flap Be Used for Reconstruction? 85 What Are the Alternatives to Free Flap Reconstruction? 85 Decisions Regarding Adjuvant Therapy 86 References 87 Chapter 6: Larynx Cancer 91 Decisions in Clinical Evaluation 91 Clinical Situations 91 Supraglottic Carcinoma 91 Glottic Carcinoma 91 Assessment of the Pre-epiglottic and Paraglottic Spaces 93 What Is the Best Method to Assess Thyroid Cartilage Invasion? 93 Should an Ultrasound, CT, or MRI Scan of the Neck Be Obtained? 96 Tumor Volume and Prognosis 96 What Other Imaging Studies Are Appropriate? 97 Should the Patient Undergo Panendoscopy? 97 Decisions in Treatment 98 Clinical Situation 98 Decisions Regarding the Primary Tumor 98 Are the Outcomes of Transoral Microsurgery and Radiation Comparable in the Treatment of T1–T2 Larynx Cancers? 99 Local Control and Survival 99 Quality of Voice 100 Ultimate Larynx Preservation 100 Resection Margins 100 How Wide a Margin of Normal Tissue Should Be Resected Around the Tumor in Endolaryngeal Surgery? Should Frozen Section Examination of the Margins Be Used Routinely? 100 T3, T4 Tumors with Minimal Cartilage Invasion 102 Surgery 103 Supracricoid Laryngectomy 103 Total Laryngectomy 104 Radiation and Chemotherapy 104 T4 Larynx Cancer (Fig. 6.3b) 107 Decisions Regarding the Neck 108 The N0 Neck 108 Can the Neck Be Observed and Treated Only If Metastases Become Apparent? 108 Sentinel Lymph Node Biopsy 109 Is It Feasible, Is It Effective, Is It Practical? 109 Selective vs. Modified Radical Neck Dissection 110 Why Is Selective Neck Dissection II–IV the Elective Operation of Choice for Larynx Cancer? 110 Should Lymph Nodes in Level IIb and Level IV Be Included Routinely? 111 The N+ Neck 111 Decisions Regarding Adjuvant Postoperative Therapy 111 Management of the N+ Neck When the Primary Cancer Is Treated with Radiation with or without Chemotherapy 112 References 115 Index 121 Front Matter....Pages i-ix Evidence-Based Medicine....Pages 1-2 Oral Cavity Cancer....Pages 3-26 Oropharynx Cancer....Pages 27-49 Cancer of the Nasopharynx....Pages 51-63 Cancer of the Hypopharynx....Pages 65-82 Larynx Cancer....Pages 83-112 Back Matter....Pages 113-116