Ashok R Shaha – Conservation Surgery in Head and Neck Oncology

Written by Ashok Shaha

The management of head and neck cancer over the years has generally been radical surgery and use of adjuvant therapy in selected cases.  Patients presenting with advanced stage head and neck tumors would generally require the addition of radiation and chemotherapy to standard surgery.  Several nuances have been made in the last 100 years in the management of head and neck cancer initially starting with radical surgery, subsequently understanding the biology of the head and neck cancer and applying appropriate surgical procedures.  Conservation surgery became popular starting from the 1970s, initially in the management of laryngeal cancer and subsequently in almost every aspect of head and neck tumors.  The classical radical neck dissection popularised by George Crile and Hayes Martin is rarely performed now, in view of modified neck dissection where preservation of the vital structures is important. Preservation of the accessory nerve is quite critical in the quality of life and shoulder function.

Even though conservation surgery has become quite popular, the principle of oncologic treatment which is adequate surgical resection is still maintained in every case. It is just the change in the approach of managing these tumors.  We need to recognise that surgical procedure should be anatomically and biologically sound and conforming to the principles of oncology.  Conservation surgery implies satisfactory surgical resection to preserve form and function without compromising oncologic effectiveness of the procedure.  There has been a major shift from radical to conservation surgery in breast, thyroid, rectum, soft tissue sarcoma, melanoma, and head and neck tumors.  This is directly related to better understanding of the biology of the head and neck cancer and maintaining quality of life of the patients suffering with advanced head and neck cancer. Various aspects of conservation surgery include management of the neck with modified neck dissection initially popularised by Oswaldo Suarez from Argentina.  Segmental resection of the mandible is now performed only when the tumor is directly invading the mandible, otherwise a marginal mandibulectomy should be considered. Preservation of the facial nerve is quite critical in the management of salivary gland tumors. Conservation surgery for laryngeal cancer has made a major impact on the functionality of the larynx, avoiding laryngectomy in a majority of the patients. This is the concept of organ and function preservation initially popularised as partial laryngectomy and extended to subtotal laryngectomy.  Management of the tumors of the skull base has also seen major changes from radical craniofacial resections to endoscopic skull base surgery.  

The management of thyroid cancer has evolved and conservation surgery is most applicable in thyroid cancers with major emphasis on lobectomy, modified neck dissections and selective use of central compartment dissection.  The sentinel node biopsy has played a major role in the management of patients with melanoma, especially intermediate thickness melanomas. Technology has also made a major impact, including endoscopy, robotic surgery and the use of energy devices such as harmonic and LigaSure. In summary, conservation surgery has become extremely popular and an important advance in the management of head and neck cancer. The role of the surgeon in the management of head and neck cancer will be different, modified and expanded adhering to the biology of head and neck tumors in an effort to maintain the best quality of life.