Head, Neck and Thorax Surgical Oncology

Our Achievements and USPs

• Largest series (more than 500 cases) of Trans Oral Robotic Surgeries (TORS) for cancers of oropharynx and supra glottis in Asia.
• Pioneer of Robotic Neck dissection in the Country.
• One of the Largest series of Robotic Neck Dissections in the country.
• One of the largest series of robotic surgeries for Thyroid diseases in the country.
• One of the largest series of Robotic surgeries for cancers of the Esophagus.
• Organ specific Head-Neck & Thoracic Surgical Oncology Team.

Head-Neck Cancer Services

Head-Neck & Thoracic Cancer Services at FMRI Gurgaon provides Comprehensive Cancer Care from Prevention to Palliation. A team of Surgical Oncologists, Radiation Oncologists, Medical Oncologists, Reconstructive Surgeons and other Medical Specialties work together to treat each Head-Neck & Thoracic 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. 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 voice box, 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.

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.

• 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.

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 Option

Modalities of Treatment Available for Head and Neck Cancers

• Surgery
• Radiation
• Chemotherapy
• Rehabilitation
• 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 diarrhoea. 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 FMRI Gurgaon, Head and Neck Services

• State-of-the-art diagnostic facilities, eg. MRI, PET – CT studies.
• Expert opinion - a second opinion from panel of oncology specialists, like surgical oncologists, radiation oncologists, medical oncologists, radiologists, rehabilitation team and oncopathologists
• 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.
• Continuity of care is maintained in whatever department the patient is being treated. There is continuous dialogue between members of interdisciplinary team.
• Various types of operations which are being performed by head and neck surgical oncologists are:
  • Robotic Surgery: Transoral Robotic Surgery (TORS) for oropharyngeal cancer, supraglottic cancer, hypopharyngeal cancer, thyroidectomy and neck dissections.
  • LASER Surgery: Laser excision of vocal cord (Transoral LASER Microsurgery), oral cavity lesions, precancerous lesions.
  • 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.
  • 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.
• Emergency services - Patients are attended immediately in casualty of FMRI Gurgaon 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.

Thoracic Cancer Services

As far as esophageal cancer is concerned, FMRI is a high volume centre with about 100 esophageal surgeries performed every year. The unit is one of the very few centres that do Tranthoracic Mckoewen's esophagectomy in the country. The surgeons perform Thoracic Mobilization of Esophagus regularly with Robot. The department also has vast experience in open esophageal resections post chemoradiation.

The division also caters to surgery for lung cancer - Pneumonectomy, Lobectomy and Sleeve resections and one of the few centres in the country doing Chest wall Resections for both Primary and Secondary tumors of the chest wall and Pulmonary Metastatectomy for Carcinoma breast, Sarcomas and Germ cell tumors on regular basis. The unit also deals with Mediastinoscopy and Resection of Mediastinal tumors such as Thymoma and Germ cell tumors.