Head and Neck Tumours - Resection and Primary Reconstruction

INTRODUCTION: Reconstruction after extirpation of Head and Neck cancers continue to be a surgical challenge. Majority of patients are debilitated and present with locally advanced disease. Poor long term survival and the need for adjuvant Radiotherapy demand that in most cases the reconstruction should be immediate and single stage, should allow a rapid restoration of function and should have a low morbidity. Edgerton introduced the concept of immediate reconstruction after resection of Head & Neck Cancers in 1951. We have reached an era in which we must deal with one stage, recurrence preventing operations and primary reconstructions with respect to surgeons pride but also considering justifiable economic concerns. There are now individuals and teams with enormous experience in Head and Neck tumour surgery. Improvements in imaging techniques have resulted in better delineation of tumour extent, better selection of approach and more precise planning of reconstruction. Imaging modalities as axial and coronal two dimensional CT, Interactive three dimensional CT, MR imaging, Angiography, Spiral CT and software packages enabling interactive CT and MRI manipulation allow mock resections to be performed on the screen. If ablative surgery has been carried out elsewhere, the ability to use mirror imaging to superimpose the normal side as the deformed side provides real insight into the volume of hard and soft tissue needed to reconstruct the defect. AIM OF STUDY: The main objectives of this clinical study are 1. To discuss the age and sex incidence in our study. 2. To discuss the anatomical site of tumour. 3. To discuss the pathology and grading of tumour. 4. To discuss the type of resection done. 5. To discuss the previous modalities of treatment as chemotherapy and radiotherapy. 6. To study the type of reconstructions done. 7. To study the post operative complications. 8. To discuss the post operative management. MATERIALS AND METHODS: MATERIALS: This work includes the study of 50 patients with a diagnosis of tumour of the head and neck region who were subjected to surgical extirpation of the disease either curative or palliative and the defect was reconstructed primarily. The patients who were admitted in Government Rajaji Hospital, Madurai Medical College , Madurai to Plastic Surgery, Surgical Oncology and General Surgery wards were studied between August 2003 – October 2005. METHODS: The methods include obtaining information from patients, thorough clinical examination and doing necessary investigations for management. All informations were entered in a proforma specially designed for this study. METHODOLOGY: The patient’s name,age, sex, symptoms and its duration were obtained. Personal history like smoking, alcohol consumption and diet pattern were obtained. Patients were examined in detail for secondaries and operability. Basic investigations like blood Hb estimation, urine examination, blood sugar and renal parameters like urea, creatinine were done. Serum protein levels were assessed. X ray chest and ECG were taken. The extent of the disease is noted by X ray of the local region, CT scan and MRI as indicated. Tissue diagnosis and its grading were assessed. Cardiac status was examined by specialist of our institution. Diabetic patients were treated on Diabetologist opinion. Based on the above investigations, patients were assessed for general anaesthesia and managed surgically. Intraoperative, post operative complications were noted and managed accordingly. All the patients were reviewed in our OP department. OBSERVATIONS: Total of 1508 cases of cancer were admitted in our hospital. Out of this 151 cases were head and neck malignancies. 50 of this cases were taken up for study. All cases were in the age group from 6 – 80 years. 48 % cases were male and 52 % were female in our study. In this study, 4 % of cases had lesions over scalp, 2 % in forehead, 14 % in eyelid, 2 % in the eye, 12 % in the nose, 10 % in the lip, 12 % in the oral cavity, 38 % in the cheek, 2 % in the submandibular region and 4 % in the neck region. Most of the lesions were in the cheek. In this study 52 % were squamous cell carcinoma, 28 % were basal cell carcinoma, 6% were meibomian carcinoma, 4 % were haemangioma, 4% were neurofibroma, 2 % were papilloma, 2% were adamantinoma , 2 % were retinoblastoma and 2% were Rhabdomyo sarcoma. In this study, 82 % were well differentiated and 18 % were poorly differentiated tumours. In this study, 56 % of cases were cured and 44 % were given palliative treatment. Out of 50 cases 34 % had cardiology opinion before surgery. Patients on antihypertensive / anti anginal drugs were examined for cardiac status by clinical outlook, ECG and ECHO. 4 % had diabetologist opinion, 12 % had opthal opinion, 4 % had neurosurgery opinion, 2% had cardiothoracic, 2 % had radiotherapist opinion and 2% had ENT opinion. In this study, 16 % had orocutaneous fistula , 8 % had flap dehiscence at business end, 8 % had wound infection, 4 % had bone nonunion and 2 % had delayed healing as immediate complications. 68 % had no complications. As late complications, 10 % had orocutaneous fistula, 2 % had corneal adhesions, 2% had loss of vision, 2 % had flap returned, 2 % wound dehiscence and 82 % had no complications. CONCLUSION: Collaboration and Communication of multidisciplinary teams have had a profound effect in the treatment of head and neck cancers. The ability to surgically extirpate large tumours without fear of compromising the surgical margins and to provide adequate and reliable reconstruction methods improve local and regional control of disease. The concept of maintaining quality of life has become particularly important in overall care and treatment of cancer patients. Thus even patients with a very limited life expectancy should be offered resection and reconstruction, if it is expected that their quality of remaining life would be enhanced significantly. Teams of Oncologic and Reconstructive surgeons provide state of art judgement and skill for patients, even with advanced head and neck malignancies. Above all it upholds the surgeons pride and success in human care