Salvage Operations Related to Post Treatment Complications

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals. Exploring the latest innovative research and clinical advances in the field of Oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a Medical Oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma programs. Today I'm happy to be joined by Dr. Michael Fritz. Dr. Fritz is Director of the Section of Facial Plastic and Microvascular Surgery. He's here today to talk to us about salvage operations related to post-treatment complications in cancer patients. So, welcome, Michael.

Michael Fritz, MD: Thank you Dale, it's great to be here.

Dale Shepard, MD, PhD: Maybe to start, you can let us know a little bit about your role here at Cleveland Clinic.

Michael Fritz, MD: I have been at the Cleveland Clinic since 1998, I think. I was originally a resident here and went through the program and then went away for fellowship and came back on staff. Since then, I've been in the Head and Neck Institute and my practice is pretty much uniformly focused on facial plastic and reconstructive surgery and in particular microvascular free tissue transfer.

Dale Shepard, MD, PhD: Excellent. So maybe you could give us a little background on what kind of patients you would be seeing for facial reconstruction or salvage surgeries.

Michael Fritz, MD: My patient population spans from folks with small deformities after a relatively minor, like skin cancer reconstruction in the past that have functional issues with breathing or was with aesthetic appearance. So maybe very small issues we're addressing, and then it reaches all the way to people who are going to be missing a great deal of structure of their face and external organs, including those in parts of the eyes and lips, and are going to undergo a large procedure to get the cancer out. And my responsibility is basically twofold it's to make sure they look and function as well as they possibly can, and to make sure they heal so that we can get them to any adjunctive treatment like radiation or chemo, that's planed.

Dale Shepard, MD, PhD: And so most of the patients that you see, are you seeing them as part of their initial therapy, or these oftentimes patients who have had surgery or procedures somewhere else and they're coming in to, to get some help from you?

Michael Fritz, MD: The answer is yes, both. If we see them at the Cleveland clinic with an active cancer, I see them at the onset of that process. If, my oncologists think that my role would be valuable in managing them. So, all cancers are incredibly scary, but if someone tells you, you may die from this disease, but it also may take your function, your identity, along with it, it's twofold scary. And so, it's good to have us up front saying, we're going to get you through this. We're going to make you whole, and I'm done with you when you're done with me.

Dale Shepard, MD, PhD: I guess, for people that may be listening, are there particular types of cancer that you would like to see the patients earlier than later?

Michael Fritz, MD: Sure. If it's for primary cancers, larger skin cancers, for sure, we consult with the most surgeons in conjunction with them or with the head neck cancer surgeons, if their expertise is needed. So anything that's going to involve external appearance to a larger degree. Obviously, most surgeons are excellent at the small to medium-sized defects, but if it's going to involve, say for instance, a large portion of your nose or a large portion of your eyelid or ears or the rest of your face, certainly me. In addition to that any large oral cavity, oral pharyngeal cancer, anything involves a voicebox, it's going to require a larger reconstruction. And also if anybody's had previous treatment like radiation therapy and cancer's recurred, then we have a very good idea, it's going to be a much more complex adventure for everybody and having me on board to comment is valuable.

Dale Shepard, MD, PhD: So tell me a little bit about the procedures that you typically perform and kind of some of the advances that we've made recently.

Michael Fritz, MD: I guess my biggest contribution to cancer therapy, at the clinic is really my role in microvascular reconstruction. And just to clarify, microvascular reconstruction also called free flap surgery or free tissue transfer is essentially transplant surgery that involves a patient's own body. So we're taking spare parts from other parts of the body and using them to rebuild what's missing. So obviously it can cause a lot of dysfunctions somewhere else, or it's not a good idea to take it. But for example, your fibula only bears about 2 to 5% of your body's weight. And so we can take your fibula out with a blood supply and we can make a whole new jaw or eye socket and mid-face, and we can bend it and shape it in a way that it functions and looks just like a normal one.

The advances we've made recently at the clinic, now that that kind of operation has been around since the eighties. And what's really happened over the years is it's gone from being kind of a magic show where we're very excited that the flaps just survive because the survival rate of these things used to be about 50, 60%. And everybody was on pins and needles the whole time while the tissue is healing. Now we have, and most skin centers have survival rates on the order of 97, 99 plus, which is one of the reasons why I was driven into this field because it's amazing that you can take tissue from somewhere else in the body, hookup little blood vessels that are sometimes only a millimeter in size and the whole thing lives and you can kind of shape it into what you need. And that works almost every single time.

So we've kind of stood on the shoulders of the people behind us and made that success rate higher. And I've gotten with that operation, made it less morbid for patients. But then we've also figured, well, now we have this gift of something that we can take spare parts from the body and, if we take it from the right place people can walk the same day. It doesn't really cause much dysfunction. I can take blood supply essentially and transport it, and it's very reliable and we can make it super low morbidity. So why can't we start accessing blood vessels in a different way, so we're not making big incisions anymore. And if we do that, and they don't have risk of swelling, they don't have risks of a leak, if those risks are really small and why would we keep them in the hospital anymore? So, they don't need to stay the traditional seven to 10 days, which is what free flap surgery was throughout my training and throughout most of my career.

So now we've changed the mindset on this. We've done much faster operations, smaller access procedures, and we discharge people as soon as same day, we've done some as outpatients. We've published a lot on discharge between one and three days post-op and have stone that that doesn't affect survival or patient outcomes at all. That lets us kind of open this up to doing procedures that were traditionally thought to be much too small for free tissue transfer.

So you've had a surgery on your pallet, whether it was cancer or cleft or, or whatnot, but you know, and this is obviously it's relevant to cancer and you've survived, but you have a hole in your palette. So every time you don't have your plate or your prosthesis in your mouth, you can't talk. You're not understandable. And then a lot of my folks are worried about what happens when they're old and it doesn't fit well, just like dentures don't fit well, or if they lose it, how are they going to eat? How are they going to talk? Well, now we can do a procedure that takes about three or four hours, excess vessels through an incision that's about an inch long, two and a half centimeters and send people home the day after surgery and it just fixes them. And the cost is typically a scar on their thigh. That's where we get most of the tissue that we use for these much simpler operations.

Dale Shepard, MD, PhD: And what's been the biggest breakthrough that has allowed that to happen?

Michael Fritz, MD: It's a combination of things. Part of it is the team that we have at the clinic over these years, we've become so facile with free tissue transfer. I think really that's the biggest thing is it's becoming reliable. And then there's a free flap called the anterior lateral thigh free flap that was popularized in Taiwan, in the early well mid-eighties. But in the United States, because we have thicker people here especially in the Midwest, and so the thigh isn't quite as nice as other sites in terms of thinness and pliability. We've gotten better at using that source almost exclusively because it's so much easier on folks. We've gotten really good at thinning things, and we've found this material, we didn't find it, it was always there, but we realized that the fascia lata, which is this very thin layer over the quadriceps muscle, right in the area where we harvest that flap, the blood supply when it travels through that explodes on top of it. So the fascia lata on itself is this amazing way to transport a blood supply. And it's super, super thin. It's like a couple of millimeters thick, but super strong. Using these super thin, well vascularized, low morbidity things has changed a lot. It's a combination, we're better at it, we found different ways to use tissue that's easier on folks, and then we've kind of opened our minds to using in different ways, as well, created our advances.

Dale Shepard, MD, PhD: Do you incorporate things like 3D modeling or 3D printing to sort of stage some of these procedures or what kind of technologies do you use for that?

Michael Fritz, MD: Certainly in the areas where there's very complex, boney reconstructions of the face, and these are the bigger operations that we still do. Rebuilding someone's face with a fibula free flap is not the minimal access surgery I'm talking about, those are the larger procedures which people still say about a week. A lot of folks will use 3D modeling for this. I will use it on occasion, but for a couple of reasons, one is I'm slightly older and I've grown up way before 3D modeling was available, so I'm very accustomed to doing my work without it, but also because it's art. The reason why I love what I do, it's the ultimate fusion of art and medicine. 3D modeling certainly has value in distilling some of the complex problems we have down to simpler components, but it really looks at the bony framework of the face.

And let's just say, my cancer surgeon had to take some of someone's cheek out and some of the lining around their eye, and I have to build their cheek and their eye socket. Well, if you make that bone perfect, like the 3D model would want you to do it, the eye is going to sink down because they took some volume out of the eye, and the cheek is going to be hollow on that side, because the volume of the cheek was gone. You have to start looking at, okay, I want this not to be what it was before. I want this to look like the other side when I'm done. Yes, we use that, but I think it can be overused, so we use it with kind of a judicious caution.

Dale Shepard, MD, PhD: Makes sense. What type of research is going on right now in terms of perfecting these techniques or looking into doing surgeries in areas that you're not currently doing them?

Michael Fritz, MD: Yeah. I think the most exciting stuff we're publishing on right now is this procedure called The Rescue Flap. And despite the fact that it has just a catchy name, it is actually a super valuable operation and it fills a place where there was no solution.

A condition called Osteoradionecrosis occurs when bone dies after radiation therapy, and it happens most commonly in the jaw, because it's usually proceeded by someone having a tooth that gets infected and needs to be pulled. When bone has seen radiation therapy, it doesn't matter if it's a decade or two decades previously, it just can't generate the healing process that normal bone can. It's usually problems with the teeth, but it also can be just an ulcer that someone forms in the lining say over the skull base, when they've had radiation to the back of the nose, the nasal pharynx, but it sets this cascade up where the bone dies. And it's a process that's very, very difficult to stop.

In the past, really our options were to take out the bad bone, debride it and remove the teeth that are affected and send people for treatment, hyperbaric oxygen. Hyperbaric oxygen involves usually 30 different sessions, at increased atmospheric pressure with a bunch of oxygen piped in at a high percentage, so that you get more oxygen dissolved in your bloodstream, so it delivers more oxygen to tissue. The problem with hyperbaric oxygen is number one, it's very expensive, number two, it requires a ton of patients' time, but most importantly, it hasn't really shown to be very effective in any kind of significant, Osteoradionecrosis, in randomized controlled studies there wasn't a whole lot of difference. Actually, there wasn't any significant difference with placebo.

So here we had this problem that we had no solution to, except giving someone hyperbaric oxygen, treating them with antibiotics and watching them. And then when the bone would die all the way through, say the jaw would break, well, then we had to cut it out and put a fibula bone from the leg in, which worked really well, but it's a big deal operation. It's one of those seven to 10 day things. A lot of people have trachea, feeding tubes, big scar in their neck. They get more scarring of their jaw, I mean, it's big deal. And there was nothing in between, no solution in between.

What we started doing, was in these patients who just needed a couple of teeth pulled and had some bone that was exposed, either those that had failed hyperbaric oxygen or in sometimes where we knew someone just wasn't going to respond to hyperbaric oxygen. We started transferring this fascia lata off the thigh with a minimal access approach for blood supply. Either a little facelift incision in front of their ear, a little incision over their jaw, all these things, pretty invisible. And then we just use a little drain, and we tunnel the blood vessels from the mouth through the face where we needed to sew them under a microscope. So no other incisions and essentially people felt like they had a dental procedure. What was amazing about this, is it transferred this amazing blood supply. Kind of like the equivalent of doing a heart bypass on the jaw, cause it's not just where you put the blood supply, but grows into everything else.

It would provide coverage for the jaw, a healthy new blood supply, and then it would just line over and mucosalize, so it looks just like the normal jaw. Because it doesn't, they don't have any airway risks. They don't have any risk of a leak, cause we haven't made a big incision anywhere. So they can just go home. This has worked now 97% of the time, which is published on this for Osteoradionecrosis. It just stops the process.

So instead of telling these people, "oh, we'll just intermittently treat you with antibiotics and wait until things fail and then do something big." Now we suddenly have this great in-between solution, and most folks, if you say three hour operation on your jaw, a little facelift incision, go home in a day, or you can go 30 times for this high atmospheric treatment takes you about three hours to do it. A couple of hours of driving, usually a bunch of money out of pocket for copays. Most of them will just say, "Yeah, I'll skip the hyperbaric. I'll go with the other thing." You know? So that's, I think that's the most impressive salvage procedure we're doing right now.

Dale Shepard, MD, PhD: That works with the radiation.

Michael Fritz, MD: Yeah, with radiation damaged bone, Osteoradionecrosis, the nice thing when you're talking to a patient about that, is that they don't have cancer, right. They're very frustrated. They come in and they fought their cancer and they're cured, and then 10 years later, somebody talking to them about doing a big surgery on their jaw. And they're like, "Oh my gosh, I thought I was done with this." But the great thing about it is we're not talking about cancer. When we're talking about Osteoradionecrosis, it's just the late effects of the treatment that saved their lives.

Dale Shepard, MD, PhD: Is there any benefit to this procedure for people who get Osteonecrosis of the jaw from zoledronic acid or denosumab and similar loss of bone?

Michael Fritz, MD: That's a great question, and one that we don't completely have the answer to right now. Certainly, when you debride that bone from the Osteonecrosis of the jaw, you have a large space that needs to be covered and you can get a bad secondary infection. So in that way, it's similar, but the triggering factor in the process itself wasn't about blood supply. It was about kind of a death of the bone, we think it's an osteoblast imbalance. Basically the bone is kind of just dying in and of itself rotting from within. If there's enough good bone that's not affected there, I think it's still a reasonable endeavor to cover it with this free tissue transfer. But I think it's hard to tell the edges of what's good and bad. It could still be an ongoing process. It's a little bit harder to navigate. We are definitely using that for more minor issues in that regard, but if there's significant disease and it seems to go through the bone, then we're better off just taking it out and fully reconstructing it.

Dale Shepard, MD, PhD: So you mentioned a tremendous improvement in survival of the flap itself. You talked about how maintaining function and sensation and things like that would be goals. Are there new things that are coming down through research to improve sensation in a more meaningful way or, function and say of the mouth or the eyelids or things like that?

Michael Fritz, MD: Sensation is a very difficult endeavor for us because if the major nerves are taken with cancer, it's very difficult to restore the pathway. It's typically our oncologic surgeons are going to follow that as far as they can to ensure that the cancer's not in it. So there's not necessarily something to restore continuity in. But most people actually do quite well with partial loss of sensation in their face. It's when they go to the full extreme, where you're taking the full thickness jaw out and removing possibly the second nerve that goes to your lip when it's totally numb, that's really debilitating. Again, avoiding the big operation is probably the best way to maintain sensation, in terms of function that's a whole different question.

We are now so much more aggressive about taking steps that wouldn't have necessarily been considered before. Again, because of the success rates of free tissue transfer, we can use much smaller free tissue transfers in much more creative ways. Again, if someone's completely cured of their cancer and they have a lip that scarred down to their chin and they can't close their mouth well. Sometimes we can do that with just moving tissue around, but if it's heavily radiated and that's been attempted before most folks who've been told, "Look, there's absolutely no other option," but we'll go in there and put very small free tissue transfers in there again, cause it's a low morbidity and his quality of life. These are easy decisions for us, as long as we don't make people go backwards. We're very aggressive about pushing forward.

Dale Shepard, MD, PhD: What are the biggest gaps? What needs fixed next? How do we move forward?

Michael Fritz, MD: I think the biggest gap right now is that we're still using things like fibulas from legs to rebuild jaws. It's miraculous, but we've been doing that for three decades now. What we need to find right now is some hybrid between bioengineering and vascularity. It's very hard to take something that's engineered in a laboratory and just putting it in, especially in the head neck area, you're not just asking something to do okay. If it were a leg and you put it along the leg bone and it's all wrapped in muscle and healthy tissue where you could see how that can form bone pretty easily. But in the kind of punishing world, at head and neck, it's a different story.

I think we're going to have to keep separating the tissues from the potential contamination and infection and the strain on them. But we should be able to get scaffolds, with progenitor cells in them, that will form bone and then wrap these with these really low morbidity flaps. Instead of taking a bone out of a form to rebuild the inferior part of an eye socket, why are we just making a resorbing scaffold and just obliterating that space with heavily vascularized tissue, So it's babysat? And we're looking into that.

I mean, we're wrapping rib now and that works quite well, but we can get much more high-tech. And this is where, we're starting to lean on the orthopedic surgeons and the oral surgeons who are definitely far ahead of us in terms of their technology. And microvascular guys were again, just focused on getting things to work well, getting things to live. And now, now we've succeeded in that. So it's time to start thinking out of the box.

Dale Shepard, MD, PhD: So really fascinating work you guys are doing. Certainly, appreciate all you do for our patients and appreciate your insight.

Michael Fritz, MD: That's my pleasure.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, Cleveland clinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify SoundCloud, or wherever you listen to podcasts. And don't forget you can access real-time updates from Cleveland Clinics Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.