Diagnosis and Treatment

When you see BIDMC’s head and neck cancer experts, you will start with a set of tests to thoroughly identify your condition and develop a treatment plan that works best for you. Some of these tests include:

• Physical examination/blood and urine tests.  We will examine you for lumps on the neck, lips, gums, and cheeks, as well as for abnormalities in the nose, mouth, throat, and tongue. Blood and urine tests may also be required.
• An endoscopy helps physicians see inside the throat. A thin, lighted, flexible tube called an endoscope is gently inserted through the nose into the throat and down the esophagus. You will be sedated during this procedure.
• A biopsy is taken to determine whether or not a mass is cancerous.Your physician will remove a small amount of tissue and examine it under a microscope. A common type of biopsy is called a fine needle aspiration. During this procedure, cells are withdrawn using a thin needle inserted directly into the tumor or lymph node.
• An X-ray/barium swallow creates pictures in the swallowing passageway. During a barium swallow, you will swallow a liquid containing barium, and a series of x-rays are taken.
• Your physician might recommend a Computed tomography (CT or CAT) scan to help determine size of the tumor. A CT scan creates a 3-dimensional picture from different angles which provides a clear image of abnormalities.

  Sometimes, a special dye called “contrast” is given before the scan to provide better detail on the image. This dye can be injected through an IV or given as a liquid to swallow.

• Another way to measure a tumor’s size is with magnetic resonance imaging (MRI). An MRI uses magnetic fields to produce detailed images of the body, especially images of soft tissue, such as the tonsils and base of the tongue. “Contrast” dye is given, through an IV or as a liquid to swallow, before the scan to create a clearer picture.
• Similar to an MRI, a positron emission tomography (PET) or PET-CT scan creates pictures of organs and tissues inside the body. A PET scan is usually combined with a CT scan and called a PET-CT scan, but is sometimes just referred to as a PET scan. The difference between an MRI and PET scan is that a PET scan can detect changes in cells earlier, whereas a CT or MRI detect changes a little later, as the disease begins to cause changes in the structure of organs or tissues.

After BIDMC's head and neck cancer team—including surgeons, medical oncologists, radiation oncologists, dentists, social workers and speech and swallowing experts—meets to discuss your care, you will be given a plan for treatment. Your plan depends on many factors, including the location of the cancer, the stage of the cancer and your age and general health.

Your team will work with you to determine which type(s) of treatment work best for you. Some of these head and neck cancer treatments include:

Surgery and Minimally Invasive Therapies

Surgeons will remove tumors while at the same time, sparing surrounding healthy tissue. Before surgery, you may be given radiation therapy and/or chemotherapy to shrink the tumor. These therapies may also follow surgery to destroy any remaining cancer cells.

Our program also specializes in reconstructive surgery, such as microvascular reconstruction—the transfer of tissue from one part of the body to another to restore function and appearance. Dental rehabilitation, if necessary, involves a collaboration among a highly skilled oral surgeon; an otolaryngologist (ear, nose and throat surgeon) and a prosthodontist (a dentistry specialty focusing on missing teeth).

Robotic Surgery

Often times, your surgeon will utilize a surgical robot to remove the tumor from the mouth or throat. During the procedure, the arms of the robot are strategically placed inside your mouth. The surgeon sits in a console away from you and can control the arms of the robot while sitting in his console. An assistant sits at the head of your bed to help in whatever way might be needed. The main advantage to robotic surgery is allowing the surgeon access, via the mouth, to areas that his or her hands probably couldn’t reach through the mouth itself. Additionally, there is typically less scarring and a quicker recovery time with robotic surgery versus traditional surgery.

Surgery for Skull Base Tumors

Our head and neck cancer surgeons have special expertise removing complex skull base tumors. Many of these tumors can be removed with minimally invasive approaches, which do not require making incisions through the skull.

The type of surgery used for a skull base tumor usually depends on the location of the tumor, how large it is, and the degree to which it entwines blood vessels and nerves. Our surgeons are experienced in all possible surgical approaches to these tumors and will discuss all options with you.

Endoscopic Endonasal Surgery

Some tumors, usually those located in the central part of the skull base, may be removed by surgery performed through the nostrils. This is called endoscopic endonasal surgery. It’s considered a minimally invasive procedure, because the surgeon does not have to make incisions in the skull or move parts of the brain to get to the tumor.

During the surgery, surgeons use an endoscope, a long, thin, lighted tube with a tiny camera on it, to view the inside of the nose. They place the endoscope through the nasal cavity and sinuses and then into the skull base.

Types of tumors that can be removed via endoscopic endonasal surgery include:

• meningioma - a usually non-cancerous tumor that arises from the membranes surrounding the brain and spinal cord
• pituitary tumor – a non-cancerous tumor in the pituitary gland that doesn't spread beyond the skull
• craniopharyngiomas – a non-cancerous tumor that occurs at the base of the brain, usually above the pituitary gland
• nasopharyngeal carcinoma – a cancerous tumor that forms in the upper part of the throat, behind the nose
• esthesioneuroblastomas – a rare cancer of the nasal cavity

Eyebrow Craniotomy

Our surgeons may remove a skull base tumor using an eyebrow craniotomy, in which they make an incision in the eyebrow to create a small opening in the skull. This approach provides access to tumors located in the front portion of the skull base.

Craniotomy

If a tumor can’t be easily reached using an endoscopic procedure or an eyebrow craniotomy, surgeons may need to perform a traditional craniotomy, in which they make an incision in the scalp and through the skull to remove the tumor.

This procedure may be necessary for tumors located farther back in the skull base, like an acoustic neuroma (a non-cancerous tumor that develops on the balance and hearing, or auditory nerves, leading from your inner ear to the brain). Even with this approach our surgeons place incisions in creases of your head and face to make the scar cosmetically appealing.

Radiation Therapy and CyberKnife (using high doses of radiation to kill cancer cells)

Radiation uses special equipment to deliver high-energy particles, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. Most radiation treatment for head and neck cancer will be delivered through the non-invasive CyberKnife image guided therapy system. CyberKnife delivers highly precise and focused radiation directly to the tumor, while sparing surrounding healthy tissue.

Chemotherapy and Immunotherapy (using drugs to target cancer cells)

If you are prescribed chemotherapy, your physician will let you know whether you can take it orally (as a pill) or intravenously (IV). Chemotherapy regimens vary from patient to patient. They are generally repeated several times in cycles, with three to four weeks separating each cycle to allow damaged normal cells time to recover. Immunotherapy is now being used successfully to treat head and neck cancer. Immunotherapy boosts the body’s own immune system and uses it to fight cancer.

Voice, Speech and Swallowing Therapy

Your throat and tongue, as well as other areas inside the mouth may be affected during oral cancer surgery. As part of the treatment plan, therapists from our Voice, Speech and Swallowing Clinic will work with you to help you to eat and swallow safely to ensure that food and/or liquid goes down the esophagus and not the “wrong way” into the lungs. The process will begin with a swallowing evaluation with a speech-language pathologist. Often a video swallow or modified barium swallow may be recommended, which help show therapists whether foods or liquids are entering the airway.