HEAD & NECK CANCER SERVICES
Head & Neck Cancer Services at RGCI & RC provide Comprehensive Cancer Care from Prevention to Palliation. A team of Head & Neck Surgical Oncologists, Radiation Oncologists, Medical Oncologists, Reconstructive Surgeons and other Medical Specialties work together to treat each Head & Neck Cancer patient. They discuss majority of the cases in Multi Specialty Clinic to decide the best course of action. We discuss all options of treatment and investigations with patient and relations and follow NCCN guidelines. Head & neck cancer treatment is promptly followed by a personalized rehabilitation plan to help promote recovery and ensure an enhanced quality of life.
What is Head & Neck Cancer?
Most head & neck cancers begin in the cells that line the mucosal surfaces in the head and neck area, e.g., mouth, nose, and throat. Mucosal surfaces are moist linings of hollow organs and cavities of the body. Normal mucosal cells look like scales (squamous) under the microscope, so head & neck cancers are often referred to as squamous cell carcinomas. Some head & neck cancers begin in glandular cells and are called adenocarcinomas.
Cancers of the head & neck are categorized according to the area in which they originate:
- Oral cavity. The oral cavity includes the lips, the front two-thirds of the tongue, the gingiva (gums), the buccal mucosa (lining inside the cheeks and lips), the floor of mouth, the hard palate (bony top of the mouth), and the small area behind the wisdom teeth. (Retromolar trigone)
- Salivary glands. The salivary glands produce saliva, the fluid that keeps mucosal surfaces in the mouth and throat moist. There are many salivary glands eg. parotid submandibular, sublingual, minor ones.
- Paranasal sinuses and nasal cavity. The paranasal sinuses are small hollow spaces in the bones of the head surrounding the nose. The nasal cavity is the hollow space behind nose.
- Pharynx. The pharynx is a hollow tube about 5 inches long that starts behind the nose and leads to the esophagus (food pipe ) and the trachea (wind pipe). The pharynx has three parts
- Nasopharynx. The nasopharynx, the upper part of the pharynx, is behind the nose.
- Oropharynx. The oropharynx is the middle part of the pharynx. The oropharynx includes the soft palate (the back of the mouth), the base of the tongue, and the tonsils.
- Hypopharynx. The hypopharynx is the lower part of the pharynx.
- Larynx. The larynx, also called the voicebox, is a short passageway formed by cartilage just below the pharynx in the neck. The larynx contains the vocal cords. It also has a small piece of tissue, called the epiglottis, which moves to cover the larynx to prevent food from entering the air passages.
- Lymph nodes in the upper part of the neck. Sometimes, squamous cancer cells are found in the lymph nodes of the upper neck when there is no evidence of cancer in other parts of the head and neck. When this happens, the cancer is called metastatic squamous neck cancer with unknown (occult) primary.
Conventionally, Cancers of the eye, thyroid as well as those of the scalp, skin, muscles, and bones of the head and neck are grouped with usual cancers of the head and neck due to anatomical proximity. Brain surgery is separate super-specialty at RGCI & RC. Neuro Onco Surgery Deptt. is headed by Dr. R. S. Jaggi (M.Ch, Neuro surgery) How do we diagnose Head and Neck Cancer?
To find the cause of symptoms, a surgical oncologist evaluates a person's medical history, performs a physical examination, and orders diagnostic tests. The examination and tests conducted may vary depending on the symptoms. Examination of a sample of tissue under the microscope is always necessary to confirm a diagnosis of cancer.
We insist on clinical examination and believe that "Hand Scan is better than a CAT Scan"
- Physical examination may include visual inspection of the oral and nasal cavities, neck, throat, and tongue using a small mirror and/or lights. The surgical oncologist may also feel for lumps in the neck, lips, gums, and cheeks.
- Endoscopy is the use of a thin, lighted flexible or rigid tube called an endoscope to examine areas inside the body. The type of endoscope the Surgical Oncologist uses depends on the area being examined. For example, a laryngoscope is inserted through the nose / mouth to view the larynx; an esophagoscope is inserted through the mouth to examine the esophagus; and a nasopharyngoscope is inserted through the nose so that the surgical oncologist can see the nasal cavity and nasopharynx.
- Laboratory tests examine samples of blood, urine, or cells from the nodes.
- X-rays create images of areas inside the head and neck on film.
- CT scan is a series of detailed pictures of areas inside the head and neck.
- Magnetic resonance imaging (or MRI) uses a powerful magnet linked to a computer to create detailed pictures of areas inside the head and neck.
- PET scan uses modified sugar in a specific way so it is absorbed by cancer calls and appears as bright area on the scan.
- Biopsy is the removal of tissue. A pathologist studies the tissue under a microscope to make a diagnosis. A biopsy is the only sure way to tell whether a person has cancer.
Clinical examination Confirm the diagnosis Stage the disease Discuss the options of treatment in MSC and with patient and their relations Execute the treatment plan .
If the diagnosis of cancer is confirmed, the surgical oncologist will want to know the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Staging may involve an examination under anesthesia (in the operating room), x-rays and other imaging procedures. Knowing the stage of the disease helps the surgical oncologist plan treatment. Tumour Board/ Multispecialty Clinic Evaluation
Each and every Head & Neck cancer patient is evaluated by a special team of Surgical Oncologists (Head & Neck unit), Medical Oncologists, Radiation Oncologists, Onco-pathologists and Imaging Specialists. Depending on the age, general condition, type of pathology and stage of the disease, a custom made treatment plan is charted out for each and every patient as per International Treatment Guidelines. (NCCN - National Comprehensive Cancer Network) TREATMENT OPTIONS Modalities of Treatment Available for Head and Neck Cancers
- Targeted Therapy
The treatment plan for an individual patient depends on a number of factors, including the exact location of the tumor, the stage of the cancer, and the person's age and general health. The patient and the surgical oncologist should consider treatment options carefully. They discuss each type of treatment and how it might change the way the patient looks, talks, eats, or breathes. SURGERY
The surgeon may remove the cancer and some of the healthy tissue around it. Lymph nodes in the neck may also be removed (lymph node dissection); if the Surgical Oncologist suspects that the cancer has spread. Surgery may be followed by radiation treatment.
Head & neck surgery often changes the patient's ability to chew, swallow, or talk. The patient may look different after surgery, and the face and neck may be swollen. The swelling usually goes away within a few weeks. After surgery of neck and throat, patient may feel numb because nerves have been cut. If lymph nodes in the neck were removed, the shoulder and neck may be weak and stiff. Patients should report any side effects to their Surgical Oncologist, and discuss what approach to take. RADIATION THERAPY
Head & neck cancer in early cases may be treated with radical dose of radiation, but patient may require radiation pre operation or post operation, with or without chemotherapy. Different types of radiation may be planned for patients for example - 3DCRT, IMRT or IGRT.
In addition to its desired effect on cancer cells, radiation therapy often causes unwanted effects. Patients who receive radiation to the head and neck may experience redness, irritation, and sores in the mouth; a dry mouth or thickened saliva; difficulty in swallowing; changes in taste; or nausea. Other problems that may occur during treatment are loss of taste, which may decrease appetite and affect nutrition, and earaches (caused by hardening of the ear wax). Patients may also notice some swelling or drooping of the skin under the chin and changes in the texture of the skin. The jaw may feel stiff and patients may not be able to open their mouth as wide as before treatment. Patients should report any side effects to their Oncologist and ask how to manage these effects. CHEMOTHERAPY
Chemotherapy may be given along with radiation or alone in selected situations. The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, including blood cells that fight infection, cells that line the mouth and the digestive tract, and cells in hair follicles. As a result, patients may have side effects such as lower resistance to infection, sores in the mouth and on the lips, loss of appetite, nausea, vomiting and diarrhea. They may also feel unusually tired and experience skin rash and itching, joint pain, loss of balance, and swelling of the feet or lower legs. Patients should talk with their medical oncologist about the side effects they are experiencing, and how to handle them. TARGETED THERAPY
Targeted therapies are different than chemo therapies. They are like smart bombs vs cluster bombs of chemotherapy. These are oral form of drugs which selectively kill cancer cells. They have limited applications in head and neck cancer. WHAT WE OFFER AT RGCI & RC, HEAD AND NECK SERVICES? 1)
State-of-the-art diagnostic facilities, eg. MRI, PET - MRI fusion studies. 2)
Expert opinion - a second opinion from panel of oncology specialists, like surgical oncologists, radiation oncologists, medical oncologists, radiologists, rehabilitation team and oncopathologists 3)
Multi specialty clinics or Tumor Board to decide what is best for patient. It is good to know how to do things, since it is more important to know when and where not to do. Decisions are more important than incisions. 4)
Continuity of care is maintained in whatever department the patient is being treated. There is continuous dialogue between members of interdisciplinary team. 5)
Various types of operations which are being performed by head and neck surgical oncologists are:
- Oral Cancer - Composite resection (commando) with appropriate reconstruction, Mandibular resection and reconstruction; infratemporal fossa clearance, free flaps.
- Laryngeal cancer - Total laryngectomy, partial laryngectomy, gastric pull-up, TEP voice rehabilitation
- PNS (Maxilla) - Maxillectomy, Ethmoidectomy
- Skull Base - Lateral temporal bone resection, Anterior skull base surgery
- Thyroid- Total/partial thyroidectomy, parathyroid surgery
- Salivary Gland tumors- Parotidectomy, submandibular resections, facial nerve repair
- Neck- Various types of neck dissections including SOHND, MND, RND and extended neck dissections
- Robotic surgery - For early Oropharyngeal cancer
- LASER Surgery - Laser excision of vocal cord, oral cavity lesions, precancerous lesions.
- Endoscopy - Direct laryngoscopy under LA or GA, Microlaryngeal surgery
Home care services for Head and Neck cancer patients within NCR. We provide medicines and nutritional supplements to patients at no cost. 7)
Emergency services - Patients are attended immediately in casualty of RGCI&RC which is open 24x7. Various emergencies like Stridor, bleeding, vascular blowouts are dealt with immediately. Emergency surgery procedures like tracheostomy, external carotid ligation etc are done at any time of the day & night by competent staff. FACULTY
Head & Neck Surgical Oncology service is headed by Dr. A K Dewan and assisted by Dr. Surender Dabas. Dr. Sunil Gupta, Sr. Consultant Head & Neck Services in Medical Oncology add a feather in the cap of team. The Head & Neck team also includes maxilo-facial surgeon Dr. Puneet Ahuja, and speech therapist Mr. Sahni for laryngectomy patients. The faculty is assisted by number of Residents, Clinical Assistants and DNB candidates.
Dr. A K Dewan : Graduate from Maulana Azad Medical College (1975 Batch) with M.Ch. (Surgical Oncology) from Cancer Institute, Adyar, Chennai. Gained Experience in Tata Memorial Hospital, Mumbai. He has served in Safdarjang Hospital and in RGCI & RC from the day of inception.
Presently the Medical Director and Chief of Head and Neck services at RGCI. He practices evidence based medicine with emphasis on multimodal approach. It is the multidisciplinary team effort which gives desirable end result. The motto of the team is “Cure & Care with Passion”.
Dr. Surender Dabas : Graduate from Maulana Azad Medical College (1998 Batch) with DNB (Surgical Oncology) from RGCI & RC. During his training he was awarded distinction in Pathology. He gained Experience in Tata Memorial Hospital, Mumbai. LNJP Hospital, Lady Harding Hospital and now in RGCI & RC since March 2008. In 2012 he was awarded Chairman’s Appreciation Award. He is trained in Robotic Head & Neck Surgery and skull base surgery at MD Anderson Hospital, Houston, Texas, USA.
Dr. Sunil Kr. Gupta : is a well-renowned medical oncologist. With over two decades of experience, he has obtained his specialized training (DM-Medical Oncology) at Cancer Institute, Adyar (Chennai, India) and underwent fellowships at World’s leading cancer institute’s such as Fred Hutchinson Cancer Research Centre, Seattle and Mount Sinai School of Medicine. He has keen interest in chemotherapy and targeted therapy of Head & Neck Cancers.
Dr. Puneet Ahuja : Graduate from Maulana Azad Institute of Dental Sciences in year 1995 with Masters (in prosthodontics) from All India Institute of Medical Sciences in year 1998 and Diplomate of National Board in year 2001.
In year 2003-04 he worked in Dental Access Center of NHS Bedford, England as senior house officer with special interest in maxillofacial prosthetics and children with special needs. He has served in AIIMS and LNJP.
Mr. Sahni : Cancer Survivor and laryngeal cancer patient with esophageal voice. He motivates our laryngeal cancer patients for treatment and trains them for speech therapy and stoma care.