F. Christopher Holsinger, MD, FACS, is Assistant Professor and Attending Surgeon in the Department of Head and Neck Surgery at The University of Texas M.D. Anderson Cancer Center in Houston.
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December 2006For years, radical surgery was the only treatment for head and neck cancer (HNSCC). For intermediate and even early-stage disease, there were few surgical options that could achieve reproducible oncologic and functional results, especially for patients with laryngopharyngeal cancer. For instance, the indications for time-honored approaches in conservation surgery were limited: the supraglottic horizontal laryngectomy (SGL) and vertical partial laryngectomy (VPL) were excellent operations, but narrow selection criteria confined these procedures to infrequent use. As a result, radically ablative surgical approaches were more commonly used when optimal local and regional control was the goal.
Yet, in the 1980s, management of the neck was evolving, and the modified radical dissection, followed later by the selective cervical lymphadenectomy, became accepted oncologic yet function-sparing procedures. But there were no coincident evolution and few innovations for the management of the primary tumor. Bigger was still better when it came to managing the primary tumor. Microvascular reconstruction permitted larger and more generous resections. But despite large resections and their mutilating sequelae, postoperative radiation therapy was still needed for optimal local and regional control. This endgame in surgery may have perhaps led to a search for better options for patients with head and neck cancer.