Multidisciplinary Head & Neck Cancer Care

Head & Neck Surgery

 

We are the pioneers 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.

Our Innovations

  • 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:

Oral cavity

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.

Pharynx

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.

 

 

Treatments

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.

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.

Clinical Trials

  • Identification and Characterization of Novel Proteins and Genes in Head and Neck Cancer

    Through this study, we hope to learn more about the mechanisms, which may contribute to development and progression of head and neck cancer. The long-term goal of this study will be to develop new strategies and drugs for the diagnosis and treatment of head and neck cancer.

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  • Neoadjuvant Atezolizumab in Surgically Resectable Advanced Cutaneous Squamous Cell Carcinoma

    The purpose of this research is to evaluate whether the administration of atezolizumab before surgical resection of your tumor is feasible and to evaluate the treatment response, safety, and tolerability of atezolizumab.

    Investigator

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  • Comparing Sentinel Lymph Node (SLN) Biopsy With Standard Neck Dissection for Patients With Early-Stage Oral Cavity Cancer

    This phase II/III trial studies how well sentinel lymph node biopsy works and compares sentinel lymph node biopsy surgery to standard neck dissection as part of the treatment for early-stage oral cavity cancer. Sentinel lymph node biopsy surgery is a procedure that removes a smaller number of lymph nodes from your neck because it uses an imaging agent to see which lymph nodes are most likely to have cancer. Standard neck dissection, such as elective neck dissection, removes many of the lymph nodes in your neck. Using sentinel lymph node biopsy surgery may work better in treating patients with early-stage oral cavity cancer compared to standard elective neck dissection.

    Investigator

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  • Study of Cemiplimab in Patients With Type of Skin Cancer Stage II to IV Cutaneous Squamous Cell Carcinoma

    The primary objective of the study is to evaluate the efficacy of neoadjuvant cemiplimab as measured by Pathologic complete response (pCR) rate per independent central pathology review.

    The secondary objectives of the study are:

    - To evaluate the efficacy of neoadjuvant cemiplimab on measures of disease response, including:

    - Major pathologic response (mPR) rate per independent central pathology review

    - pCR rate and mPR rate per local pathology review

    - ORR prior to surgery, according to local assessment using RECIST 1.1

    - To evaluate the efficacy of neoadjuvant cemiplimab on event free survival (EFS), disease free survival (DFS), and overall survival (OS)

    - To evaluate the safety profile of neoadjuvant cemiplimab

    - To assess change in surgical plan (ablative and reconstructive procedures) from the screening period to definitive surgery, both according to investigator review and independent surgical expert review

    - To assess change in post-surgical management plan (radiation, chemoradiation, or observation) from the screening period to post-surgery pathology review, both according to investigator review and independent surgical expert review

    Investigator

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  • Perioperative Oral Steroids for Chronic Rhinosinusitis Without Polyps (CRSsNP)

    While oral steroids have been shown to be effective in the management of patients with chronic rhinosinusitis with polyps, its role in treating chronic rhinosinusitis without polyps (CRSsNP) is ambiguous. Despite a lack of strong clinical evidence to suggest a benefit in this disease state, steroids are often prescribed as a component of post-operative care after sinus surgery for patients without polyps. Oral steroids carry with them significant adverse effects, and should be prescribed thoughtfully. The aims of this study are to determine if oral steroids in the peri-operative period improves patient outcomes in CRS without polyps.

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  • Multispectral Imaging to Characterize Patterns of Vascular Supply Within Lymphoepithelial Mucosa in Oropharyngeal Cancer

    The purpose of this study is to characterize the blood supply at the base of the tongue and within the tonsil region. We hypothesize that high-resolution Narrow Band Imaging (NBI) will improve the diagnosis of oropharyngeal carcinoma (OPC). The goal is to provide the better assessment of tumor and thus providing better preoperative expectations to patients with OPC or tumor extent prior to radiation therapy.

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  • Panitumumab-IRDye800 Compared to Sentinel Node Biopsy and (Selective) Neck Dissection in Identifying Metastatic Lymph Nodes in Patients With Head&Neck Cancer

    This phase II trial studies how well panitumumab-IRDye800 works in identifying head and neck cancer that has spread to the lymph nodes in patients with head and neck cancer. Panitumumab-IRDye800 may help surgeons to identify metastatic lymph nodes during surgical removal of the primary tumor and/or lymph nodes of the neck with equal or better accuracy than the current methods.

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  • Investigation of Two Swallowing Therapy Models During Radiation Therapy for Head and Neck Cancer

    Vibrent Health is partnering with Stanford Cancer Center to conduct a randomized control trial (RCT) using mobile health technology to enhance adherence and improve swallowing outcomes in patients undergoing radiation therapy for head and neck cancer.

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  • TOGETHER: Track Outcomes and Guidance, Technology for Health and Effective Resources

    The goal of this project is to iteratively develop and test a TOGETHER pilot mobile app product in preparation for commercialization. TOGETHER is a mobile application on a smart software system that informal caregivers can use to develop and implement home-based care for cancer patients/survivors.

    The Technical Objectives are to:

    1. Establish the project team and obtain stakeholder feedback on what to include in the product.

    2. Evaluate IT customization requirements and HIPAA compliance security, and privacy protocols.

    3. Develop a prototype to show NCI and then a pilot version for beta and usability testing among stakeholders.

    4. Enhance interoperability and test integration into health system(s) - if feasible.

    5. Develop user support documentation for stakeholders.

    Investigator

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  • Testing Docetaxel-Cetuximab or the Addition of an Immunotherapy Drug, Atezolizumab, to the Usual Chemotherapy and Radiation Therapy in High-Risk Head and Neck Cancer

    This phase II/III trial studies how well radiation therapy works when given together with cisplatin, docetaxel, cetuximab, and/or atezolizumab after surgery in treating patients with high-risk stage III-IV head and neck cancer the begins in the thin, flat cells (squamous cell). Specialized radiation therapy that delivers a high dose of radiation directly to the tumor may kill more tumor cells and cause less damage to normal tissue. Drugs used in chemotherapy, such as cisplatin and docetaxel, work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Cetuximab is a monoclonal antibody that may interfere with the ability of tumor cells to grow and spread. Immunotherapy with monoclonal antibodies, such as atezolizumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. The purpose of this study is to compare the usual treatment (radiation therapy with cisplatin chemotherapy) to using radiation therapy with docetaxel and cetuximab chemotherapy, and using the usual treatment plus an immunotherapy drug, atezolizumab.

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  • Identification of Secreted Markers for Tumor Hypoxia in Patients With Head and Neck or Lung Cancers

    The purpose of this study is to identify and confirm new blood and tissue markers for prognosis and tumor hypoxia. Tumor hypoxia, or the condition of low oxygen in the tumor, has been shown to increase the risk of tumor spread and enhance tumor resistance to the standard treatment of radiation and chemotherapy in head and neck and lung cancers. We have recently identified several proteins or markers in the blood and in tumors (including osteopontin, lysyl oxidase, macrophage inhibiting factor and proteomic technology) in the laboratory that may be able to identify tumors with low oxygen levels or more aggressive behaving tumors.

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  • Study to Evaluate Immunological Response to PD-1 Inhibition in Squamous Cell Carcinoma of the Head and Neck (SCCHN)

    This is a single-center cross-sectional imaging and correlative biomarker study in patients with Squamous Cell Carcinoma of the Head and Neck (SCCHN). Cohort 1 will be patients with unresectable or metastatic SCCHN cancer receiving standard of care (SOC) anti-PD-1 treatment and Cohort 2 will be neoadjuvant study participants who will receive one dose of anti-PD-1 treatment prior to tumor resection or radiation. Blood sampling and tissue biopsies will be collected from both cohorts and both cohorts will undergo two whole body PET(Positron Emission Tomography)/CT(Computed Tomography) imaging with [18F]F-AraG. First scan prior to initiating anti-PD-1 treatment and second scan post initiation of anti-PD-1 treatment in Cohort 1 and prior to tumor resection or radiation in Cohort 2

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  • Individualized Treatment in Treating Patients With Stage II-IVB Nasopharyngeal Cancer Based on EBV DNA

    There are two study questions we are asking in this randomized phase II/III trial based on a blood biomarker, Epstein Barr virus (EBV) deoxyribonucleic acid (DNA) for locoregionally advanced non-metastatic nasopharyngeal cancer. All patients will first undergo standard concurrent chemotherapy and radiation therapy. When this standard treatment is completed, if there is no detectable EBV DNA in their plasma, then patients are randomized to either standard adjuvant cisplatin and fluorouracil chemotherapy or observation. If there is still detectable levels of plasma EBV DNA, patients will be randomized to standard cisplatin and fluorouracil chemotherapy versus gemcitabine and paclitaxel. Radiation therapy uses high energy x rays to kill tumor cells. Drugs used in chemotherapy, such as cisplatin, fluorouracil, gemcitabine hydrochloride, and paclitaxel work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. It is not yet known whether giving cisplatin and fluorouracil is more effective than gemcitabine hydrochloride and paclitaxel after radiation therapy in treating patients with nasopharyngeal cancer.

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  • Prospective, Multicenter da Vinci® SP™ Surgical System TORS Study

    A prospective, multicenter investigation of the da Vinci® SP™ Surgical System in Transoral Robotic Surgery (TORS) procedures for malignant oropharyngeal tumors.

    Investigator

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  • Clinical Validation of ThyroidPrint: A Gene Expression Signature for Diagnosis of Indeterminate Thyroid Nodules

    A clinical trial is proposed, to clinically validate, in a US population, the diagnostic performance of a new genetic test (ThyroidPrint). It will determine the nature of thyroid nodules that have been informed as indeterminate by cytology through a fine needle aspiration (FNA). The Genetic Classifier for Indeterminate Thyroid Nodules is a test that determines the expression of a panel of 10 biomarkers (CXCR3, CCR3, CXCl10, CK19, TIMP1, CLDN1, CAR, XB130, HO-1 and CCR7). Gene expression data is analyzed through an algorithm that generates a composite score that predicts the risk of malignancy. It´s intended use is for patients with thyroid cytology as indeterminate (Bethesda III and IV, according to The Bethesda System for Reporting Thyroid Cytopathology). This test uses a fine needle aspiration (FNA) sample.

    Investigator

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  • Panitumumab IRDye800 Optical Imaging Study

    Phase I trial to evaluate the safety of escalating dose levels of conjugated panitumumab-IRDye800 in subjects with head and neck squamous cell carcinoma (HNSCC) that undergo surgery with curative intent.

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  • Cetuximab IRDye800 Study as an Optical Imaging Agent to Detect Cancer During Surgical Procedures

    This study is an open label, single institution, Phase 1 dose-escalation study to determine the safety profile of cetuximab-IRDye800 used in subjects with head and neck squamous cell carcinoma (HNSCC) that undergo surgery with curative intent. Participants will be given a dose of an approved head and neck cancer drug (Cetuximab) along with an investigational study drug called Cetuximab-IRDye800. Cetuximab-IRDye800 is a drug that is given prior to surgery that attaches to cancer cells and appears to make them visible to the doctor when he uses a special camera during the operation. The investigators are evaluating whether or not the use of the study drug along with the special camera will better identify the cancer while patients are in the operating room.

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  • Talactoferrin in Treating Patients With Relapsed or Refractory Non-Small Cell Lung Cancer or Squamous Cell Head and Neck Cancer

    This phase I trial studies how well talactoferrin works in treating patients with relapsed or refractory non-small cell lung cancer (NSCLC) or squamous cell head and neck cancer. Biological therapies, such as talactoferrin, may stimulate the immune system in different ways and stop tumor cells from growing

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  • Imaging and Biomarkers of Hypoxia in Solid Tumors

    Hypoxia, meaning a lack of oxygen, has been associated strongly with a wide range of human cancers. Hypoxia occurs when tumor growth exceeds the ability of blood vessels to supply the tumor with oxygenated blood. It is currently understood that hypoxic tumors are more aggressive. Current methods for measuring hypoxia include invasive procedures such as tissue biopsy, or insertion of an electrode into the tumor. EF5-PET may be a non-invasive way to measure tumor hypoxia.

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  • Transoral Surgery Followed By Low-Dose or Standard-Dose Radiation Therapy With or Without Chemotherapy in Treating Patients With HPV Positive Stage III-IVA Oropharyngeal Cancer

    This randomized phase II trial studies how well transoral surgery followed by low-dose or standard-dose radiation therapy works in treating patients with human papilloma virus (HPV) positive stage III-IVA oropharyngeal cancer. Radiation therapy uses high-energy x-rays to kill tumor cells. Drugs used in chemotherapy work in different ways to stop the growth of tumor cells, either by killing the cells or by stopping them from dividing. Giving radiation therapy with chemotherapy may kill any tumor cells that remain after surgery. It is not yet known how much extra treatment needs to be given after surgery.

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Head & Neck Surgery