The surgical management of parapharyngeal cancer

Prof Rogério Dedivitis - University of São Paulo School of Medicine, São Paulo, Brazil

In the past century surgery was the preferred approach however due to the stigma of the definitive tracheotomy the organ preservation protocols have become preferred by a good part of the specialists. However, we have to remember that very high density tumours present a better survival rate when you perform the total laryngectomy or, if possible, a partial laryngectomy when appropriate instead of the organ preservation protocol. Those protocols which are based on radiation therapy combined with chemotherapy, they provide an anatomical preservation of the organ however the quality of life of the patients is not so good. The most part of them have their larynx preserved, however the function of those larynx are not so good; the patients are not able to swallow properly and parts of those patients still remains with their tracheotomy because of inhalation of liquids, mainly of liquids.

Is this more common in Brazil?

The most common cancer in Brazil among men is prostate cancer. If you join oral cancer with laryngeal cancer we are supposed to have every year about 12,000 new cases of head and neck tumours. So when you join those two sites you can consider that head and neck cancers as a whole is the most common, the second most common, in Brazil. On the other hand, among women thyroid cancer nowadays is the fifth most common so it’s becoming more and more common, maybe because of the early diagnosis because other doctors, not specialists in head and neck surgery, more and more are asking for ultrasound in order to verify if the patient has some nodes in the thyroid gland. So it’s very common in our country to diagnose very small papillary thyroid cancers.

Regarding thyroid cancer, it’s not recommended that you perform a survey in patients without any kind of risk for having thyroid cancers because when the cancer can be verified under the clinical examination the final outcome regarding survival and oncological results is absolutely the same. So we are performing surgeries in order to remove tumours of half a centimetre but we are not sure that it brings any benefit to our patients.

What are some alternative treatments for laryngeal cancer?

When we are approaching early tumours, early laryngeal tumours, we can perform endoscopic resection using a cold knife or using a laser approach. It’s a kind of endoscopic surgery with very good outcomes. The other option is the exclusive radiation therapy without chemotherapy for early tumours. The outcome is very similar, we have above 95% survival after five years and voice outcome is very similar. Some papers in the literature report a better outcome using radiation therapy regarding voice but other papers consider that the outcome is very similar using a laser approach or radiation therapy. However, if you do not perform the radiation therapy as a first approach you can save this kind of treatment in order to use it in the same patient in the future in case of recurrence or in case of a secondary tumour in the head and neck region.

Do you have a summary message for doctors watching?

The main issue to be addressed is that the early diagnosis is very important. So approaching patients with persistent dysphonia, mainly if they are men over 40 years, smokers, drinkers, those patients should be carefully verified, examined by a specialist, it’s very important