Head and Neck Oncology Program (HNOP)
Stanford Head & Neck Center
HNOP is a pioneer of major scientific breakthroughs
- Organ preservation approaches to head and neck cancer.
- New drugs for head and neck squamous cell carcinoma (HNSCC) and extending uses of existing drugs to HNSCC and nasopharyngeal carcinoma (NPC).
- Advanced radiation therapy techniques that limit toxicity and improve outcomes.
- Minimally Invasive and Robotic Surgery
- Stem cell work that extends the findings of the first paper, demonstrating the existence of “cancer stem cells” in HNSCC by researchers from Stanford and Michigan in 2007; and a 2009 Stanford study establishing that stem cell properties of patients’ malignancies correlate with prognosis. This work led to subsequent stem cell papers in 2011 and 2012.
- Normal tissue stem cell studies to identify salivary gland stem cells and to manipulate them for preservation and/or restoration of salivary gland function from radiation damage.
- HNOP’s breadth of research studies and protocols including treatment of intermediate and advanced disease as well as hypoxia imaging.
- Creation of the first head and neck multidisciplinary tumor patient conference (tumor board; 1976) in the U.S.
- Introduction of the first use of chemotherapy with irradiation for head and neck squamous cell carcinoma (HNSCC), which is the basis of organ-preservation chemoradiation in the U.S.
- Close working relationships with:
- Neurosurgery, Interventional Radiology, and Neuroradiology,which are critical for complex open and endonasal endoscopic skull base surgery.
- Endocrinology in the treatment of thyroid cancer.
- Dermatology in the treatment of advanced skin cancers.
- Innovative research by physicians now at Stanford that demonstrates the utility of the FDA-approved Mobetron for intraoperative radiation therapy.
- Contributing research in a Phase II trial of immunotherapy in intermediate and advanced surgically-treated HNSCC. A Phase III trial is now planned.
- Leadership in the head and neck disease site committee of the Radiation Therapy Oncology Group to develop new nation-wide clinical trials in head and neck cancer.
- Biomarker studies to identify novel circulating biomarkers for prognostication and post-treatment surveillance in head and neck cancer.
- Strong links to developmental therapeutics such as the advancement of new drugs to treat cancer.
- Provision of a full range of treatment options that include minimally invasive surgery, robotic surgery, stereotactic radiosurgery such as CyberKnife, microvascular reconstruction, intraoperative radiation therapy (IORT), and new chemotherapy trials.
What is Head & Neck Cancer?
Head and neck cancer is a term that can include the broad array of tumors which may arise in this anatomically diverse region of the human body. Most often, the term head and neck cancer refers to tumors that arise from “squamous” cells that line the moist, mucosal surfaces of the mouth and throat. In fact, 95% of head and neck tumors are squamous cell carcinoma.
Tumors of the thyroid, salivary, and parathyroid glands, as well as cancers of the brain, nose and paranasal sinuses, esophagus, and eye, are not usually categorized as head and neck cancer. Furthermore, tumors of the skin, muscle and bone arising in the head and neck are also typically not included in this term.
Head and neck cancer is then further classified by its location within the mouth and throat:
The lips, the oral tongue” (the forward two-thirds or front part of the tongue), the gums lining the upper and lower jaws, as well as the lining inside the cheek. The area known as the floor of the mouth is a mobile area between the lower jaw and gum and the oral tongue. The roof of the mouth or “hard palate” is also included as part of the oral cavity. Finally, a small triangulated area of mucosa or gum lining the area behind the last wisdom tooth is called the“retromolar trigone” and is also part of the oral cavity.
In medical terminology, the throat is known as the pharynx. In fact, the pharynx is supple tube or funnel that connects both the nose and mouth to the swallowing tube or esophagus. The pharynx is composed of three parts: the nasopharynx (the area just behind the nose); the oropharynx (behind the oral cavity and in the back of the mouth], and the hypopharynx, which surrounds the voice box and leads into the esophagus.
The larynx critical not only for the production of speech, but also breathing and swallowing. The “supraglottic” larynx has a valve called the epiglottis, which covers the larynx during swallowing to prevent “aspiration” of food into the lungs.
HNOP offers multi-disciplinary, collaborative and integrated evaluation and care for patients with head and neck cancers.
Minimally invasive or endoscopic head and neck surgery (eHNS) is a dynamic new approach that allows surgeons to remove tumors with use of a specialized endocopes and cameras without external incisions and usually with little or no change in speech, appearance, and swallowing function.
An endoscope is a long, thin tube with special lighting and a narrow lens through which the surgeon can view organs and tissue inside of the body. For throat cancers, the surgeon inserts the endoscope through the patient’s mouth, and a microscope provides an excellent image of the tumor. Using very precise, state-of-the-art surgical instruments that are also inserted through the mouth, the surgeon can perform the operation without an external incision.
eHNS has several advantages in many cases. Some of these advantages are:
- Reduced risk of blood loss
- Lower pain levels
- Fewer days spent in the hospital
- Quicker return to a normal diet and faster recovery time
- Less scarring, with improved cosmetic appearance
In some cases of throat cancer, eHNS may reduce or even eliminate the need for chemotherapy and radiation therapy.
At Stanford, your team of surgeons, oncologists, and radiologists will work together to determine the best course of action for you. The goal with eHNS is always the same: to eliminate the cancer while minimizing the risks and recovery time associated with traditional cancer care.
Chemotherapy or radiation therapy may still be necessary after eHNS. When chemotherapy and radiation therapy cannot be avoided through surgery, eHNS may still hold advantages for patients. Faster recovery after eHNS means patients can usually begin chemotherapy and radiation therapy earlier. And the smaller incisions with eHNS heal more quickly than larger incisions and are less likely to become infected.
Two types of eHNS, transoral robotic surgery (TORS) and transoral laser CO2microsurgery (TLM), have revolutionized the treatment for throat cancer.
Transoral Robotic Surgery (TORS)
Robotic head and neck surgery is a state-of-the-art procedure that offers the advantages of computer technology, specialized surgical instruments and advanced three-dimensional imaging. At Stanford Medicine, the da Vinci ® Surgical System, created by Intutive Surgical, is now used in select cases of urologic, gynecologic, thoracic and head and neck cancers.
The da Vinci ® system is a highly specialized surgery system. Four robotic arms hold a high-definition video camera and three tiny surgical instruments. The surgeon controls these robotic arms from a computerized operating console, inserting them into the patient’s body through slender tubes (cannulas) and then performing the operation. The surgeon views the entire operation on a large screen. The da Vinci ® system’s sophisticated technology eliminates even very small hand tremors in the surgeon’s movements.
The da Vinci ® system is the only surgical robot approved by the Food and Drug Administration and is most often used for prostate surgery.
In 2007, Dr. Holsinger was among the first surgeons in the world to perform TORS. Since then, Dr. Holsinger has performed more than 100 TORS procedures for tumors of the oropharynx, larynx, and hypopharynx.
Transoral Laser Microsurgery (TLM)
TLM was first proposed in 1972 and is now widely used for tumors of the throat and larynx (voice box). At Stanford Medicine, your surgeon will help you decide if TLM is right for you. Patients undergoing TLM for throat of larynx cancer are placed under general anesthesia. The surgery is performed directly through the mouth and therefore does not leave a visible scar. The surgeon inserts a thin endoscope through the mouth and a specially designed microscope lets the surgeon see the tumor and surrounding tissue during the surgery.
With TLM, a highly specialized carbon dioxide (CO2) laser beam is used instead of a scalpel to cut through the tissue. Unlike other types of lasers, the CO2 laser beam generates minimal heat energy. This limits damage to normal structures around the tumor, such as important nerves, blood vessels, and muscles which are important for speech and swallowing.
Different CO2 laser systems are available for use with TLM, if you are diagnosed with early-stage cancer of the larynx (voice box), then Digital AcuBlade laser surgery may be used. With this method, CO2 laser is delivered through a specialized robotic adapter that creates precise incisions. The system, designed by Lumenis Surgical specifically for larynx and vocal cord surgery, uses a computer with an operating microscope. The surgeon programs the computer by entering information about the specific type of procedure that will be performed, the laser beam pattern, the incision length and the depth that the laser will penetrate. The surgeon positions the laser beam on the larynx or vocal cord and performs the procedure by manipulating a joystick on an operating microscope. The CO2 laser moves in straight, curved, or circular patterns to sculpt the most precise incision with the least effect on surrounding normal tissue.
Another type of laser used with TLM is flexible fiber-optic CO2 laser. If your surgery for throat cancer has a high risk of bleeding, surgeons at Stanford Medicine may use thulium laser instead of CO2 laser. The skilled surgeons at Stanford Medicine will choose between a pulsed laser beam and a continuous laser beam to perform the best surgery for you.
Endoscopic Thyroid and Neck Surgery
For patients with thyroid cancer or benign (noncancerous) thyroid tumors who need surgery, Stanford Medicine offers traditional thyroid surgery with an open incision in the neck or, in carefully selected cases, robotic thyroidectomy or minimally invasive thyroid surgery. Methods used with robotic thyroidectomies magnify the view of the operative field, increasing the surgical precision and reducing the risk of complications.
Robotic surgery uses state-of-the-art technology that allows surgeons to safely remove certain thyroid tumors through discrete incisions several inches from the neck. Because no incision is made in the neck, the patient avoids a neck scar.
The da Vinci ® surgical system is a highly sophisticated computerized system that is used for robotic thyroid surgery. The surgeon cuts a 1-inch to 2-inch incision in the folds of skin under the patient’s arm and inserts the da Vinci ® system’s robotic arms, which have been customized to resemble standard surgical instruments. The surgeon guides the robotic arms underneath the skin toward the thyroid gland.
The surgeon views the surgical field on a 3-D high-definition screen, magnified up to 10 times. The skilled surgeons at Stanford Medicine control the da Vinci ® system’s robotic arms as one might control conventional surgery. The instruments on the robotic arms can move with seven degrees of movement and rotate 540 degrees, giving the surgeon the ability to manipulate delicate tissues with precision.
Robotic thyroidectomy is not available for all thyroid tumors. If your thyroid tumor is less than 3 cm in size and is likely to be benign (non-cancerous), then robotic surgery may be an option. Your surgeons will help you decide the best approach for you.
Minimally Invasive Video-Assisted Thyroidectomy (MIVAT)
Minimally Invasive Video-Assisted Thyroidectomy (MIVAT)uses an incision in the neck that is less than 1-inch long to reach the thyroid glands. This incision is smaller than the incision with conventional thyroid surgery. A tiny scope is used to project the operative field onto a computer screen at 10-times original magnification, improving the surgeon’s view during the surgery.
Endoscopic Skull Base Tumor Surgery
The skill base is a complex, highly specialized region deep within the cranium (skull). It is surrounded by vital structures of the head and central nervous system. At Stanford Medicine, a team of highly-skilled specialists in head and neck cancer and neurosurgery work together to provide the highest level of care for patients with tumors of the skull base.
Treatment for tumors of the skull base may involve surgery, radiation therapy, chemotherapy, or a combination. For some patients, a conventional open surgical approach provides more advantages. For others, a minimally invasive or endoscopic approach is recommended.
With endoscopic skull base surgery, the skilled surgeons at Stanford Medicine acces the tumor through tiny holes in the skull or the back of the sinuses. Endoscopic skull base surgery may reduce your hospital stay, decrease complications from surgery, and help you recover faster.