The Latest in Oropharyngeal Salvage Neck Dissection

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm looking forward to speaking with a returning guest, Dr. Brandon Prendes, a head and neck cancer surgeon here at Cleveland Clinic's Department of Otolaryngology-Head and Neck Surgery. Dr. Prendes, welcome back to Head and Neck Innovations.

Brandon Prendes: Thanks for having me again today, Paul.

Paul Bryson: Well, today's episode's going to build on your previous appearance, and we'll dive into some of the latest in oropharyngeal salvage neck dissection. But for our new listeners, if you don't mind, can you just start by sharing some background on yourself, where you're from, where you trained, and then just kind of the nature of your clinical practice. Because you’re one of the more broadly skilled members of our team and actually take care of a lot of different things within your group, so if you could share a little bit of that, I would love to hear it.

Brandon Prendes: Sure. I grew up actually on a west side suburb of Cleveland, and then I went away for training. I went to undergraduate at the University of Michigan, medical school at University of Pennsylvania, and then I went to the west coast to University of California San Francisco for otolaryngology residency. And then after that I returned here for a one year fellowship in microvascular reconstructive surgery. That was at the Cleveland Clinic in our department. And then I stayed on afterwards and I've been on faculty for eight years, as you said. I have a range of things I focus on in practice. I think the large volume of it is head and neck cancers and tumors. And then I do a lot of reconstructive surgery, both for malignancies but also for other processes of the head and neck injuries or radiation complications, a lot of surgery for radiation necrosis and doing free tissue transfer, so bringing tissue from other sites in the body to reconstruct defects and help peel wounds. So that's my practice. I also take care of some salivary gland issues, both salivary stones and salivary obstructions, but that's a smaller part of my practice at this point.

Paul Bryson: Dr. Prendes, at COSM last month, you contributed some research on the topic of comparing outcomes for patients versus without a vascularized free flap for coverage in salvage neck dissection. Can you share an overview of the research, and how do the findings compare to the current standard of care? And then also what made you want to investigate this topic?

Brandon Prendes: Good. Yeah, so I'll start with the end of that question. I think as you know Paul, but maybe some of our listeners don't know oropharyngeal cancer, which is essentially throat cancer, is a growing problem pretty much all over the world, but certainly in the United States and certainly in the practice we have here in Cleveland. So we're seeing a lot of patients with throat cancer present to our clinic. It actually has outgrown the rates of cervical cancer that we're seeing in this country. And both of these diseases are HPV-related, so high risk human papillomavirus that lives in the throat. The good thing about these cancers is that they're highly treatable. The patients typically present with a small cancer in the throat, but kind of large neck nodes that have cancer that is spread to them. Luckily, even with neck nodes involved in the cancer, these are still often stage one cancers, which is good.

So a lot of our patients will live a long time and many of them will be cured of their cancer. The one thing about this disease though is that while a lot of people get chemotherapy and radiation as a primary treatment, and this will eradicate all of their disease, there's a portion of patients, maybe five to 10% of all patients that come in where they'll have residual disease after treatment, and that's where salvage neck dissection comes in. Basically, salvage neck dissection is defined as removal of lymph nodes in the neck. In patients who have basically had residual cancer in their neck lymph nodes after the primary treatment, again, that's often radiation and chemotherapy or some combination thereof. And this neck dissection in a patient who's had treatment before is often complicated by things like wound healing issues, scarring, fibrosis, and things like the need to take out structures that are normal.

And so that can mean anything from the big muscle that kind of covers over their neck called the sternomastoid muscle to things like the spinal accessory nerve, which is movement and strength muscle for the shoulder. So here at the Cleveland Clinic, we've had a long history of using free flaps, as I described before, transfer of non-irradiated tissue with a really good blood supply from one site to another. And so we've employed this a little more liberally for patients than at some other centers. So for years now, in certain cases of salvage neck dissections, we've brought tissue from places like the thigh to bring in healthy non-irradiated tissue when we're taking out these recurrent cancers to kind of allow healing of the neck, give the patients better appearance and contour. And we think that these free flaps can also provide other benefits in terms of long-term function protection from additional treatments like re-radiation. And so that's kind of our practice here and something that's not done standardly in a lot of other centers.

Paul Bryson: Yeah, I mean I think it's pretty interesting - the potential trying to preserve function like you talked about. For the listeners that may encounter patients that are survivors of this type of cancer, the fibrosis and the stiffness and the things like that can really be debilitating. And it seems like they're protective too, when you have to remove additional structures, the fresh, healthy, non-radiating tissue also provides coverage of vascular structures that are normally protected by things that are removed oncologically for this.

Brandon Prendes: Yeah, that's right, Paul. So as I mentioned, the survival rate for these oropharyngeal cancers that are HPV-related are better than a lot of our other head and neck cancers. And so there is a lot more thought put into what is the long-term function that these patients are going to have, because we do have great hope that even in the setting of these persistent cancers in the neck, they may have good long-term survival. So we really need to be focused on what's their quality of life going to be down the road.

Paul Bryson: And what did you find in the study? What were some of the highlights?

Brandon Prendes: Yeah, so it was really, it was a retrospective study and our numbers weren't huge, but we thought it was important as an initial kind of proof of safety kind of study. So we looked at a group of patients who had had this salvage neck dissection and didn't have any vascularized tissue placed in their neck, which again is pretty standard across the country and has been for years. And then we looked at a separate group of patients who had vascularized tissue flaps placed in the neck, and we saw some things that we pretty much expected. The patients who had the free tissue transfer stayed a little bit longer in the hospital five days as opposed to two on average. They had a little more of a recovery for a few months, but at a year, their function was essentially equivalent to the patients who didn't have a vascularized tissue transfer.

And the group that had undergone the free flaps had more extensive neck dissections, more radical neck dissection. So basically what we saw is these free flaps for this type of patient, they were safe. They required a little more of a healing phase, but then they kind of got the patients to where we hope they would be in terms of function and healing. And an important factor that we saw is that the large majority of our patients who underwent these types of salvage surgeries, especially for oral pharynx cancer, had some additional treatment down the road. And that's where we think these flaps will really be important, protecting those patients who get second rounds of radiation or further things like immunotherapy down the road or additional chemotherapy treatments protecting their necks from the complications of those additional treatments.

Paul Bryson: Well, congratulations to you and the team for this work, and looking forward to more on this topic. And you got me thinking about a few questions. There's a number of, I feel like interesting things happening with HPV-related cancers for one, and sort of my world, we see laryngeal papillomatosis, so it's an HPV infection locally in the larynx and sometimes the pharynx, it's benign most of the time, but we're starting to hear about some therapeutic vaccines that are coming through the pipeline for that condition. What's the current state of that sort of work for oropharyngeal carcinoma?

Brandon Prendes: Yeah, so first, prevention's a huge part of oropharyngeal cancer, and I think that there's more and more education about that. We're seeing increasing rates of vaccination for our young people, and the vaccine is now approved up to the mid-forties for our adults as well as our adolescents. So it's really important to long-term try to prevent this disease so we don't have to treat a lot of people, and we do think that those vaccines will be really helpful. That's the GARDASIL vaccine for HPV. So I think that's one important thing.

First and foremost, in terms of therapeutics, there's a lot of new studies with de-escalation trials, we know these patients do quite well with their treatment. So trying to pick patients who need less treatment, sometimes a small robotic surgery with a kind of minimally invasive tonsillectomy or lingual tonsil removal and a neck dissection, and then either no radiation afterwards or lower doses of radiation and avoidance of chemotherapy. There's all kinds of trials across the country regarding that type of treatment paradigm. And then right here at the Cleveland Clinic, there's interest in developing vaccines that actually can be therapeutic. The Silver Lab run by Natalie Silver is working on bringing that to fruition in terms of clinical trials for patients with regard to cancer vaccines, and that's super exciting, obviously.

Paul Bryson: And then I had heard about these liquid biopsies. What's that all about?

Brandon Prendes: Yeah, liquid biopsy is basically a blood test that can detect small portions of basically DNA from cancers to determine patient's response to treatment. And so that'll be used in these de-escalation trials as a marker as to what patients need additional therapy after their upfront surgery or radiation. And it'll also be used as a marker for early detection of recurrence. That'll probably be, we all think, way more sensitive than any imaging study, so we can know what to look out for. We can say to patients, “Hey, you don't really need that yearly scan because this blood test is negative, and we know that the chances of finding something is going to be quite low.”

So I think that's on the horizon, and everyone who treats head and neck cancer is excited about that, both for HPV related disease, but also for non HPV related head and neck cancers. It's really, really exciting time to be in this field, I think.

Paul Bryson: Yeah, I really appreciate those perspectives. It really does feel like we're sort of in this frontier zone where lots of new things are indeed happening in this space. Well, as we wrap up, I appreciate your time. It's great to have you back on the podcast. Any take home messages for our listener?

Brandon Prendes: Yeah, so I think the exciting thing for me is we're doing more and more the Cleveland Clinic as being such a referral center and seeing complicated, maybe previously treated cases like these salvage cases. It's allowed us to kind of look at those patients and try new things that maybe aren't done elsewhere to try and get them better oncologic outcomes, better functional outcomes. So with regards to these salvage next studies, we're headed in the direction of trying to collect prospective data for a larger study to kind of hone in on the finer details of the functional benefits that these flaps might give people. And there's even thoughts on things like lymphedema, which is a big problem for cancer patients. This post-treatment swelling that breast cancer patients get in their armpit, will head and neck cancer patients get that swelling in the neck, and there's some thought that transferring tissue from other sites of the body is going to help prevent that and treat that. So all these things are really exciting to us, and we're working on those with multiple different groups across the enterprises.

Paul Bryson: Well, to read more about our latest head and neck cancer research, visit our consult QD website at ConsultQD.ClevelandClinic.org/HeadAndNeck. That's ConsultQD.ClevelandClinic.org/HeadAndNeck. And to speak with one of our specialists or submit a referral, please call our Cancer Answer Line at 866.223.8100. That's 866.223.8100. Dr. Prendes, thanks for joining Head and Neck Innovations.

Brandon Prendes: Thanks so much for having me, Paul. Really appreciate it.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.