Dr. Levine added, In dealing with head and neck cancer for the past 30 years, it has always been my credo that one should continue to maintain an open mind and permit data and outcomes to be one’s guide. Physicians in all professions would do well to maintain and adhere to the axiom of Alexander Pope: ‘Be not the first by whom the new are tried/Nor yet the last to lay the old aside.’
Explore This IssueJuly 2008
He said that when doctors present options to patients, the first consideration must always be probability of a cure. A second question, especially when dealing with facial tumors, involves morbidity and cosmetic outcomes. He showed examples of several patients who underwent extensive cranial facial resection and had almost no long-term evidence of disfiguring scarring.
Not one patient in our series has been deterred or psychologically prevented from pursuing an active and fruitful life, Dr. Levine said. While no scar is preferable, all things being equal, this should not be a strong selling point or more importantly not be a determining factor in patients’ choice unless the outcomes are comparable.
He said that the decision requires comparisons of cure rates, which for cancer is influenced by the ability to provide clear surgical margins.
Although sometimes difficult during a craniofacial resection or an en bloc dissection, it is possible to have an incised margin that is determined, Dr. Levine said. Going for piecemeal dissection utilizing endoscopic resection, it can be difficult to resect the tumor with surgical margin confidence. Even proponents of this technique have concerns about their confidence in the adequacy of surgical margins obtained utilizing this approach.
A Team Approach
Dr. Levine also said that treatment of complicated tumors requires a team approach. Appropriate treatment requires knowledge of the disease process and the range of other adjuvant therapies and their support staff, he said.
With that in mind, if one proposes to resect these tumors endoscopically, it should be performed by a team that has counseled the patient about the potential need to perform a craniofacial resection-now euphemistically called the open approach-and be prepared to do so while the patient is still on the operating room table during the initial procedure.
Performing the endoscopic approach then finding the tumor to be unresectable via this approach [or] packing the cavity and then referring the patient to a craniofacial team to perform the resection is not appropriate, he asserted.