Head & Neck 2017

The First LAU Head & Neck Symposium

February 10, 2018 — 8 AM to 6 PM
Le Bristol Hotel, Beirut, Lebanon


Session 1

Chairman: Alain Sabri
Panelists: Selim Chammas, Marwan Ghosn, Joseph Makdessi, Michel Saade & Caroline Samaha

1. Oropharyngeal Cancer HPV, the Robot, and De-escalation Therapy
Kerry Olsen, MD – Mayo Clinic, USA

Oropharyngeal cancer is one of the fastest growing cancers worldwide.  The majority of these tumors are found in the tonsillar and tongue-base area and are of an advanced stage.  They generally involve a younger age group, are more common in males, but have up to 90 percent five-year survival rate due to the main etiology of the tumor HPV virus.  There are more than two-hundred types of human papilloma viruses but HPV 16, 18, and 31, account for up to 80 percent of oropharyngeal squamous cell cancers.  There is definitely a relationship of the tumor to oral sex and although the prognosis is good, debate continues regarding the optimum treatment for this condition.  In contrast to HPV negative tumors that have a three-year survival rate of 57 percent, HPV positive tumors have a three-year survival rate of 82 percent.  This is for stage III and IV tumors treated with radiation and chemotherapy.

In the management of oropharyngeal cancer, treatments with a role to play include surgery, radiation, chemotherapy or often in combination.  It is important to look at the patient, the tumor, and factors pertinent to the treating physician to arrive at the optimal management.  Although there are numerous surgical approaches to tumors in the tonsil and oropharyngeal cancer, in discussing surgical management, the transoral approach continues to assume greater interest and importance in effective management.  Currently in the author’s practice, up to 50 percent of oropharyngeal cancers are now managed by the transoral approach.  Results with this have been excellent with a five-year local control rate of almost 92 percent.  Regardless of the mechanism of removal whether with a cold knife, cautery, laser, or robot, results should be the same if frozen section evaluation of the margins are done and tumor excision is complete.

The robot has assumed greater importance in the management of oropharyngeal cancer, and the Mayo Clinic experience is now over 600 cases, almost equally divided between the tonsil and tongue base locations.  Almost 90 percent of the patients are male, 92 percent of them are positive for HPV, and the majority stage IV malignancies.  Treatment includes surgery alone, surgery and radiation therapy, or surgery and chemotherapy and radiation therapy.  Local control is now at 98 percent, local and regional control, 92 percent, and it is important to note that the average time to any recurrence is less than one year.  This presentation will also review the advantages of transoral robotic surgery versus assisted open surgery.

Unfortunately, the use of standard radiation and chemotherapy for HPV oropharyngeal malignancies has very significant unintended consequences that include severe short term and increasing long-term complications.  These include PEG dependency, marked swallowing difficulties, pain, esophageal stenosis, mandibular osteoradionecrosis, death, marked fibrosis, xerostomia, carotid stenosis, and hypothyroidism.

Because of the significant side effects of these tumors, the Mayo Clinic has started a new de-escalation therapy for management of HPV oropharyngeal cancer to try to continue the favorable oncologic results but significantly reduce the side effects from chemotherapy and radiation therapy.  The use of de-escalation therapy to date has been incredibly successful with overall survival of almost 100 percent and to date there have only been three local or regional recurrences and four distant recurrences.  At this point, we have no patient who requires the long-term use of a feeding tube or gastrostomy tube.  The use of aggressive de-escalation has resulted in local control rates that are comparable to historical controls and has led to a marked reduction in post-treatment side effects and improved long-term swallowing function and quality of life.  Finally, this presentation will review issues pertinent to cost, other treatment issues, and give final recommendations for this cancer to manage it smarter and more effectively. 

2. The Dr. ASSEM SERHAL MEMORIAL LECTURE: Immunotherapy in Recurrent and Advanced Head and Neck Squamous Cell Carcinoma
Fadlo Khuri, MD – President of the American University of Beirut

Head and neck cancers represent a heterogeneous series of diseases with differing primary sites, differing metastatic patterns and vastly different outcomes. Recent evidence has shown that in addition to the traditional risk factors such as tobacco and alcohol, viral etiologies of cancers of the hypopharynx and the nasopharynx predominate. These diseases, HPV driven hypopharyngeal cancer and EBV-driven nasopharyngeal cancer, both have better prognoses than those caused by tobacco and alcohol consumption. Trials focusing on the treatment of recurrent and metastatic head and neck cancer using either oncolytic viruses or immunotherapy have shown considerable promise in these diseases. Oncolytic viruses targeting p53 deficient cancers and RAS driven cancers have proceeded, with direct tumor infusion in combination with chemotherapy and systemic approaches both tested. Given the absence of immune surveillance in many of these tumors and the phenomenon of immune tolerance that characterizes these diseases, recent trials targeting the PD-1 receptor to overcome immune tolerance have been of great interest. This has resulted in a recent randomized phase III trial of Nivilomab for recurrent squamous cell carcinoma of the head and neck, and it resulted in a doubling of the one year survival rate compared to standard therapy, irrespective of PDL-1 expression or P 16 status. Other approaches targeting innate immunity and combining these approaches with checkpoint inhibitors also are in advanced stages of development.

3. Updates and Standards of Care in Treatment of Nasopharyngeal Carcinoma
Fady Geara, MD – American University of Beirut 

Nasopharyngeal carcinoma (NPC) represents a distinct entity among head and neck cancers with well defined geographic distribution, a strong relation with Epstein-Barr Virus, and a remarkable radiosensitivity and chemoresponsiveness. NPC is endemic in Southern China and is quite common in the Mediterranean basin. In the middle east, NPC is very common in North African countries, and in Saudi Arabia where NPC ranks 2nd among all head and neck cancers, and 9th among all cancers. Based on estimates from regional tumor registries and international studies on cancer incidence, the annual incidence of NPC in Lebanon is estimated around 0.3-0.7/100,0000 inhabitants. NPC often presents in locally and/or regionally advanced stages and is typically treated by a combination of chemotherapy and radiation therapy. The prognosis of NPC has improved significantly over the past three decades due to advances in disease management, diagnostic imaging, radiotherapy technology, and broader application of systemic therapy. Despite the excellent local control with modern radiotherapy, distant failure remains a key challenge and has been the subject of numerous trials attempting to address this mode of failure. Trials on induction chemotherapy, concurrent chemoradiotherapy, adjuvant chemotherapy after definitive radiation or combination of thereof have been conducted in endemic and non-endemic regions with variable outcome on disease control, toxicity, and short and long term morbidity. Today the overriding standard of care for locoregionally advanced NPC remains concurrent chemoradiation followed by adjuvant chemotherapy when patients can still tolerate additional therapy. This 20 year old standard has been repeatedly challenged by a variety of treatment combinations without significant results. On the other hand, advances in molecular technology have helped to decipher the molecular pathogenesis of nasopharyngeal carcinoma as well as its etiologic association with the Epstein-Barr virus. This in turn has led to the discovery of novel biomarkers that are being investigated for their prognostic impacts and for possible drug targeting. In this presentation we will review and appraise the key literature on the current management of nasopharyngeal carcinoma and future directions in clinical research.

4. Role of Induction Chemotherapy in HNSCC
Hady Ghanem, MD – Lebanese American University 

Concurrent chemoradiotherapy (CCRT) has been considered to be the standard of care for locally advanced squamous cell carcinoma of head and neck (LA-SCCHN). Whether induction chemotherapy (IC) with CCRT improves the clinical outcomes or not is still a subject of controversy. In this talk we will expose the pros and cons of using IC, its indications, complications as well as the special situations for its optimal use. We will present the data to support or not the use of this specific treatment among the various therapeutic modalities of LA- SCCHN.

Session 2

Chairman: Rami Saade
Panelists: Abdul Latif Hamdan, Antoine Jaklis, Maher Kasty, Clement Khoury & Fadi Nasr

1. Aggressive Non-Melanoma Skin Cancer 
Randal Weber, MD, FACS – MD Anderson Cancer Center, USA

The most common malignancy afflicting humans is non-melanoma skin cancer (NMSC).  While accounting for fewer deaths than other cancers, due to its prevalence and a higher incidence in the head and neck, cost implications for the healthcare system are high as are cosmetic and functional sequelae.  This presentation will review the demographics, pathogenesis and the phenotypic characteristics of aggressive behavior.  Discussion will include the implications of patient, tumor and treatment factors such as immunosuppression, tumor differentiation, regional metastasis, perineural invasion, and the strategies for the appropriate use of adjuvant therapy that impact tumor control and patient outcomes.  Advances in genetic analysis and identification of therapeutic targets are creating opportunities for administration of novel therapies that may improve tumor control and lessen the morbidity of treatment.  This presentation will review current evidenced based treatment and the future state of emerging targeted therapies. 

2. Nuances in Management of Advanced Laryngeal Squamous Cell Carcinoma
Amine Haddad, MD – Hôtel Dieu de France

Survival in advanced laryngeal cancer did not follow the improvement seen in other Head and neck cancers. It has coincided with the advent of laryngeal preservation protocols. This has warranted recent modifications of the guidelines for its management; why has this happened, and what are the elements to look for before selecting the appropriate management plan in T3 and T4a laryngeal carcinomas.

3. Lessons Learned from 35 Years of Salivary Gland Surgery
Kerry Olsen, MD – Mayo Clinic, USA

This presentation will review experience with more than 2000 parotidectomies performed during the past thirty-five years.  The essential preoperative evaluation and assessment to determine parotid from non-parotid regional disease will be reviewed.  In general, observation is poor advice and it is always problematic to advise observation on the basis of a cystic lesion alone.  One of the common problem areas is the discovery of parotid masses on imaging studies for a nonpalpable or asymptomatic lesion.  In general, the surgeon should treat all of these as they would if they were palpable.  In general, if there is a palpable asymptomatic parotid mass and one can feel the entire tumor, no additional evaluation or imaging is necessary.

There are three key components to adequately perform salivary gland surgery.  One is knowledge of tumor behavior, the second is mastery of the regional anatomy, and third is obtaining necessary operative experience and capability.  The presentation will briefly review issues pertinent to facial nerve identification and vagaries of presentation of certain parotid tumors.  In addition, the main goals of any parotid surgery remain to remove the tumor safely, to avoid capsular dissection if possible, and to identify and avoid facial nerve injury.  The surgeon will spend their entire career trying to learn when it is safe or necessary to do more or less than a removal of a portion of the parotid gland.

Some of the things not to do besides observation are open biopsies, enucleation, relying on imaging or ultrasound alone, underestimating the extent of the tumor, and not being prepared to fully care for the patient’s tumor.  The surgeon is only as good as their pathologist.  The surgeon and pathologist need a close working relationship, as the surgeon needs to know if the tumor is benign or malignant, lymphoma or carcinoma, low grade or high grade, and the status of any intraparotid nodes and margins.  With this information, the surgeon can determine if a deep lobe removal is necessary, if a neck dissection is necessary, and what the extent of the resection should be.  The importance of understanding and correctly managing all aspects of the parotid gland, superficial and deep, for malignant disease will be reviewed.

Too often, with malignant disease, a lack of understanding of tumor behavior causes decision making to suffer.  One common scenario is the patient who undergoes a partial or superficial parotidectomy and permanent pathology shows a malignant lesion.  What should be done and why is discussed for these cases.  Mismanagement of salivary gland neoplasms remains a major problem.  Since the majority are benign, the unusual neoplasms are not treated effectively.  There often is a tendency to rely on radiation therapy to correct an ineffective operation.  To manage salivary gland neoplasia effectively, one needs a dependable pathologist, knowledge of anatomy, appropriate treatment experience, and long-term follow up.

In general, the surgeon should be able to match the patient’s expectations of a safe successful tumor removal with preservation of facial nerve function.  Salivary gland surgery is challenging but enjoyable and always unique.

4. Special Topics and Recent Advances in Thyroid Tumor Surgery
Alain Sabri, MD, MPH, FACS – Lebanese American University 

Thyroid cancers comprise a group of pathologies that are interesting in presentation and clinical course. The treatment of thyroid cancers is often controversial. This presentation will focus on several special topics in thyroid tumor surgery. The majority of thyroid cancers include well differentiated thyroid carcinomas, mainly papillary and follicular (comprising 80-90% of all thyroid malignancies). Other rarer forms of thyroid cancers include medullary and anaplastic carcinomas in addition to lymphomas. The incidence of well differentiated thyroid cancers has been increasing quite steadily over the past few decades. The factors for this are unknown. The mainstay of treatment for well-differentiated carcinomas includes surgery. There are many other adjunct therapies which include radioactive iodine treatments, possible external radiation in advanced and recurrent disease, some new immunotherapies & other treatments will be discussed.

Special topics and controversies will be addressed as well. These include invasive thyroid cancers, management of the nerve, the trachea, oesophagus and other structures involved by cancer: Extra-thyroidal cancer negatively impacts prognosis, the 10 year survival drops from above 90% in well encapsulated cancers to 45 % in this patient population.  Substernal Thyroid tumors will also be addressed and these comprise a special group of disorders and require multidisciplinary care including thoracic surgery. Pediatric thyroid cancers are usually rarer, and have certain particularities that differentiate them from adults including a higher incidence of cancer in pediatric thyroid nodules. Perioperative voice assessment and management including Fiberoptic endoscopy, videostroboscopy, and vocal cord medialization are important in managing patients with thyroid carcinomas. A thorough review of the literature will be performed, in addition to case presentations which illustrate the above facts.

A multidisciplinary approach to the management of thyroid cancers including specialists from the fields of otolaryngology, reconstructive surgery, thoracic surgery, endocrinology, radiation therapy, medical oncology, radiology, pathology and other related specialties is paramount to ensuring the best patient outcomes.

Session 3

Chairman: Kerry Olsen
Panelists: Anthony Al Hawat, Fares Azoury, Emile Brihi, Georges Chahine, & Bassel El Baba

1. Controversies in Management of Oral Cavity Squamous Cell Carcinoma
 Antoine Melkane, MD – Hôtel Dieu de France

Oral cavity squamous cell carcinoma (OCSCC) is a major global health issue. This entity represents a heterogeneous group of tumors affecting different subsites in the oral cavity. Besides having a bad prognosis, advanced lesions requiring surgery and adjuvant treatment can sometimes result in poor functional outcomes.

In Western countries, OCSCC rank first among head and neck cancers, in terms of incidence. However, with the decreasing tobacco and alcohol consumption, their incidence -along with the overall incidence of head and neck squamous cell carcinomas- is stabilizing or slightly dropping. In Lebanon, OCSCC rank second after laryngeal cancers and seem to be stable in incidence.

In this presentation, the updated TNM classification for OCSCC, with the recent introduction of depth of invasion in the T staging and extra-capsular spread in the N staging, will be exposed.

The major controversial topics concerning the management of OCSCC will then be reviewed. These mainly include the management of the clinically N0 neck in early oral cancers, with an emphasis on the role of depth of invasion and indication of the sentinel node biopsy; the changing epidemiology of oral cavity cancers with the recent rise in incidence of young female tongue cancers; and the confusing role of Human Papillomavirus in oral cavity cancers.

2. Pathology Margin Assessment in Head and Neck Squamous Cell Carcinoma Resections
Selim Nasser, MD – Lebanese American University & Clemenceau Medical Center 

Pathologic evaluation of surgical margins in Head and Neck squamous cell carcinoma is a challenging task including several considerations:

3. Radiologic Considerations in Head and Neck Cancer Imaging
Raghid Kikano, MD – Lebanese American University 

Major Head and Neck Cancer staging changes in AJCC 8th Edition; what changed and what are the radiological implications.

The major head and neck cancer staging changes include Novel staging-related oropharyngeal cancer (utilizing p16+ surrogate marker), recognition of significance of extra nodal extension of tumor, review of interval addition of head and neck-specific cutaneous malignancy staging, with a new classification for cervical nodes of unknown primary and restructuring of pharyngeal cancers.

The radiology’s role in the changes of head and neck cancer staging landscape, focuses on imaging differentiations in view of the new classification.

In HPV + oropharyngeal cancers, the nodal involvement imaging is typically cystic with regular margin of hypodense internal focus, on post contrast cross sectional imaging (lower stage for presentation), while is solid or necrotic with irregular hypodense margins (with higher stage for same presentation) for HPV- cancers.

The addition of new variable specifically, extranodal extension, in nodal categorization across head and neck cancers (not applicable to nasopharynx, HPV+, or mucosal melanoma) which is defined as extension of metastatic nodal tumor beyond lymph node capsule, with only unquestionable clinically proven ENE, that is supported by radiological evidence, is to be used for clinical staging and has a profound impact on prognosis with significant upstaging.

The addition of classification for conundrum of the occult primary tumor and the radiological assistance in determining lack of primary site, and assessing degree of nodal categorization.

4. Microvascular Free Tissue Transfer for Major Head and Neck Defects
Sami Melki, MD – Lebanese American University 

The head and neck region is one of the most anatomically complex region of the human body with a conglomeration of different vital functions. It is the part of the human body that projects our identity to the outside world. Its function is to allow breathing, eating and most importantly speak and communicate. When disease such as cancer affects this area, ablative surgery can lead to unacceptably high loss of function and form.

Reconstruction of the head and neck is therefore a critical part of any ablative surgery. Over the past century, multiple methods, new techniques and technology have been devised to address the unique and complex needs of this anatomical region. Free flap reconstruction has revolutionized the field and has allowed oncologic surgeons greater freedom in aggressively resecting cancers, whether primary or recurrent ones. No matter how big the defect is, whereas a regional pedicled flap might be limited by bulk or arc of rotation, a free flap can always be harvested from the most suitable location and be used to restore form and function.

Furthermore, with the current trend in using concurrent chemotherapy and radiation, salvage surgery is made safer because a free flap brings new, non-radiated tissue to the head and neck and allows for lower complication rates and better functional and cosmetic outcomes.

Session 4

Chairman: Randal Weber
Panelists: Raja Fakhoury, Georges Farha, Nabil Moukarzel, Marc Mourad and Rabih Said

1. Endoscopic Management of Anterior Skull Base Neoplasia
Samer Fakhri, MD – American University of Beirut 

Endoscopic techniques have been increasingly utilized for the treatment of anterior skull base neoplasms over the past 20 years.  We will focus on the minimally-invasive, multi-disciplinary management of sinonasal neoplasms.  Minimally invasive technology, which includes endoscopic techniques and computer-aided surgery, offers less morbidity and potentially better surgical outcomes compared with traditional surgical approaches, which have well-described morbidity and limitations.  Technological advances have driven a shift from external rhinologic procedures to computer-aided, endoscopic endonasal approaches as surgeons have sought to optimize treatment outcomes and minimize surgical morbidity.  The presentation will strive to describe both the treatment strategy and the rationale for endoscopic approaches to the skull base.  Relevant anatomic relationships and specific techniques will be presented through still and video images; clinical correlates will illustrate relevant principles.  Office-based endoscopy, CT, MRI/MRA, and PET, will be discussed.  Endoscopic techniques for the repair of anterior cranial base defects will be described.  Intraoperative surgical navigation with CT-MR fusion and 3D-CTA will be presented.  The limitations of endoscopic approaches will also be discussed.  Published reports will be critically analyzed.

Educational Objectives:

2. Endovascular Management of Hypervascular Lesions of the Head and Neck 
Michel Mawad, MD – Dean of the Lebanese American University Gilbert and Rose-Marie Chagoury School of Medicine

The Head & Neck area can be the host of a variety of conditions that may pose a challenge to the treating Head & Neck surgeons.

These conditions include: neoplastic disease both benign and malignant, arteriovenous malformations, veno-lymphatic lesions, post traumatic vascular injuries, epistaxis, etc.

The management of these lesions require a multidisciplinary approach and a constellation of skills that are often complementary and improve the patient’s outcome.

In addition to the surgical know-how and expertise, often time the management of hyper-vascular lesions of the head & neck requires good endovascular expertise and appropriate equipment and devices.

The most common vascular condition we encounter is epistaxis, either benign or related to underlying neoplastic disease or a genetic condition. The treatment of benign recurrent or intractable epistaxis is best performed by de-vascularizing the nasal mucosa using embolic material, either in the form of particulates or liquid polymer/adhesive.

The other common hyper-vascular conditions encountered in the head & neck include vascular neoplasms such as juvenile angiofibromas, paragangliomas, meningiomas extending into the carotid space and schwannomas arising from the cranial nerves. The best outcomes in these particular neoplasms are seen when a complete surgical resection is preceded by adequate pre-operative devascularization using endovascular techniques.

Arteriovenous malformations of the head & neck are also best treated using endovascular obliteration either as a sole form of treatment or combined, when necessary, by complete surgical resection.

Veno-lymphatic malformations of the head & neck are another category of challenging conditions that are best treated solely by percutaneous sclerotherapy procedures using sclerosing agents such as alcohol or the antimitotic agent Belomycine.

“Blow-out” of the carotid artery is encountered in advanced head & neck cancer that has eroded into the carotid space and can be associated with life-threatening hemorrhagic complications requiring emergent occlusion of the parent artery with endovascular means.

3. Head and Neck Cancer Treatments and Quality of Life
Rami Saade, MD – Lebanese American University

Head and Neck Cancers represent a heterogenous group of diseases with a wide spectrum of behavior and biology. Treatment trends for many subsites have shifted from a primarily surgical management to organ preservation. However, organ preservation does not equate with preservation of function. Oncologically, we have achieved unprecedented locoregional control rates and overall survival rates but at the expense of increased toxicities. The Disease and its Treatment have a disproportionate impact on all aspects of patient quality of life with heavy symptom burden, long-term impairment and disability.

After organ preservation, the new challenge at stake is functional outcome and health related quality of life in Head and Neck cancer patients. Throughout the presentation we will highlight the need for a multidisciplinary effort to decrease treatment toxicities and optimize functional outcomes. We will go over the new technologies, innovative approaches and the trials that are trying to establish a role in improving head and neck cancer patients’ quality of life. We will then provide a more in-depth insight on what defines quality of life in the Head and Neck Cancer population. We will present the instruments available to measure it and provide a critical appraisal of their significance and interpretation. We will focus on the functional domains and review the health related quality of life achievements by various treatment modalities. Finally we will conclude with the role of patient reported Quality of Life questionnaires as an important outcome measure of cancer care and a predictor of survival.

4. Value Based Head and Neck Cancer Care
Randal Weber, MD, FACS – MD Anderson Cancer Center, USA

Health care costs continue to rise despite governmental measures and payer attempts to implement cost control strategies.  Resources are wasted on non-evidenced based care, treatment variability and over utilization.  Moving towards a value based care delivery system will improve quality and decrease costs.  The widely endorsed definition of value based care is the outcome achieved divided by the cost to achieve that outcome.  As an extension of this concept, our institution has defined value as the outcome achieved plus the patient’s experience during their journey through the health care system divided by the cost of care.  We consider cancer care is not great unless the patient perceives it to be so.  This presentation will review economic forces driving health care delivery towards value and our institutional and programmatic strategies to enhance the patient experience.

5. Hospice and Palliative Care
Hibah Osman, MD – Balsam Lebanese Center for Palliative Care

Head and neck cancers are commonly associated with a heavy burden of symptoms. The impact of the tumor or its treatment on basic functions such as eating and speaking and the often visible nature of the disease can result in significant physical and psychosocial suffering. Palliative and supportive therapies should be integrated into the care of head and neck cancer patients early in the course of illness regardless of whether the intent of treatment is curative or not. In this session we will address the management of common symptoms associated with the treatment of head and neck cancers and review guidelines and palliative care in head and neck cancers.