6.4.7: 7. Surgical Considerations in Under-Resourced Settings

Unreliable follow-up: With patients with malignant tumours and unlikely to attend regular follow-up to detect early recurrence or metastases, electively treat Levels Ia,b, IIa and III of the neck by surgery (preferably) or radiation therapy

Unavailability of postoperative radiation therapy (PORT)

• Most patients with salivary malignancy receive PORT (Indications for PORT)
• Not having PORT to treat residual microscopic cancer or nodal metastases has the following surgical implications:
  • Consider resecting nerves adherent to a malignant tumour
  • Elective neck dissection Levels Ia,b, IIa and III for malignancies
  • Consider who not to offer surgery for advanced tumours when outcomes without PORT will be poor

Palliative surgery

• Patients often present with advanced cancers that might either be treated with surgery and PORT, or palliated with radiation therapy
• In the absence of radiation, it raises the issue of surgical palliation for incurable salivary cancers to improve quality of life
• Some patients with adenoid cystic carcinoma with lung and bone metastases at presentation may survive some years (van Weert S, et al. Adenoid cystic carcinoma of the head and neck: A single-center analysis of 105 consecutive cases over a 30-year period. Oral Oncol. 2013 Aug;49(8):824-9)

Hence “palliative surgery” can be recommended for selected patients

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