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Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

Welcome. Today we are talking about some of the exciting technology advancements in oral oncology. My guest is Dr. Anthony Morlandt. He’s an oral and maxillofacial surgeon and an Associate Professor at UAB Medicine. So, Dr. Morlandt, I’m glad to have you with us. Tell us a little bit about the history of how cancer has been treated classically and what’s changed over the years?

Anthony Morlandt, MD, DDS, FACS (Guest): Well head and neck cancer is a longstanding human condition. It’s been around for probably millennia and in recent recorded history; we have cases like President Ulysses S. Grant who would receive thousands of cigars every year, when he was in the White House and when he died in 1885, he spent the last six months of his life treating his head and neck cancer with cocaine mouth rinses and bourbon. He had no option for treatment. The tumor was unresectable at diagnosis and he ultimately died in Mt. Meader, New York, handwriting his memoirs. So, his wife had some source of income after she died. Mark Twain published the memoirs and it provided income for their family for the rest of her life.

But when we have a patient like President Grant, and we compare him to someone like Michael Douglas who had the same tumor in a similar location; their outcomes couldn’t have been more different. The way cancer has classically been treated is first with surgery. Surgery has been used for about 150 years for these tumors. Surgery involves removing the cancer itself with wide margins, 1 to 1.5 centimeters in most cases for squamous cell carcinoma, usually quite a bit larger for the more rare sarcomas that we see in the head and neck.

And then in the 1950s, 60s and 70s; the rise of radiation therapy came, and radiation therapy is typically not used for first line treatment or oral cavity tumors because of all the vital structures such as the mandible and the teeth and the oral tongue and even the lips which can be damaged by high dose radiation therapy.

And in the current era, we are seeing the rise of immunotherapy and patient specific personalized medicine that can be used where a specific mutation is identified within the tumor and then targeted therapy is administered to that patient to try and shrink specific tumors that have been refractory to surgery and radiation therapy and typical cytotoxic chemotherapy.

Host: Doctor, due to that intricate nature of these types of cancers and facial reconstruction, which we will talk about at another time; what have been some of the past challenges that you’ve noted and how do you feel that some of this technology, endoscopic instrumentation coupled with improved imaging and localization; how has that helped to improve outcomes and what have you seen?

Dr. Morlandt: Yeah so, one example of that is an upper jaw cancer. For example, Grover Cleveland had a maxillectomy for an upper jaw tumor which was – later there was question about whether that represented malignancy or not. But he had that done on a boat during his presidency in secrecy with ether anesthesia and cocaine local anesthesia injection. But when the upper jaw is removed; it used to be felt that if any tissue was placed over that defect to close off the site of this cavity or the nasal cavity; it would be very difficult to identify cancer recurrence. And so some things we use to identify recurrence in those cases are a flexible fiberoptic endoscope that can be placed into the nasal cavity in clinic after using a little bit of vasoconstrictor and local anesthesia aerosolized into the nose; and that can identify tumors that may arise in hidden locations such as the sinus or the maxillary sinus or the nasal cavity.

We also can use CT imaging. So, there are plenty of papers in the literature that show the sensitivity of CT scans especially those with contrast allow us to cover those defects with a free-flap, for example and still pick up a recurrence very early.

The literature tells us though and the NCCN guidelines suggest that patients who have a recurrence whether it’s one year or two years all the way up to five years after their cancer treatment; patients tend to identify those recurrences themselves and present because of those new findings and so that may be a new neck mass, it may be new pain, swelling in the primary site, difficulty swallowing. In the case of a maxillary or sinus cavity cancer; it may be nose bleeds, intractable nose bleeds or new sinus congestion.

So, many times the patients are identifying a change and so that’s why we have a very robust survivors clinic, surveillance clinic after their treatment where the patients can come in and be seen by a physician or an advanced practice provider for up to five years after their treatment and then once a year after that for life just to be sure that we have that relationship open with the patient and family so that if they find any change; they can come back and see us.

So, detection before diagnosis is important. Detection after treatment is important. And then we have some ways that we can identify patients who need the very best in terms of long-term function up front. We have a combined oral oncology clinic which consists of an ablative cancer surgeon, a resection surgeon, a reconstructive surgeon who has advanced training in microsurgical principles and maxillofacial prosthodontist. And this is a dentist who finishes dental school, finishes prosthodontic training for three years and then does an additional one to two years in head and neck cancer prosthetics. And that may include replacement of a missing eye, a missing ear, a missing nose, missing teeth or jaw, all using silicone or acrylic or cobalt chromium or vitalium, all of these different materials that can be used for replacement of missing hard and soft tissues.

So, the prosthodontist sees every patient before surgery and many times they can optimize using 3-D imaging, 3-D scanning and even 3-D printing. They can optimize their long-term function after surgery. So, it’s a team approach.

Host: Isn’t that fascinating and I was going to be asking you about the 3-D computer planning for presurgical resection and intraoperative navigation. Tell us when you are looking at all of these factors and technology Dr. Morlandt, what do you think is the physician learning curve? Is this something that you feel is happening around the country? Is it catching on as it were? Are there plenty of resources available for physicians to learn all of this new technology for this very specific type of cancer?

Dr. Morlandt: Oh, I think there are. I think we live in an age now where we are digitally driven. My children can pick up an iPhone and get places I could never go surprisingly and so, I’m always amazed that the technology, the interfaces are pretty easy to use. I think what’s so fascinating about an academic practice is we’re just standing on the shoulders of those who’ve gone before. So, you know 40 years ago, there was no option for reconstructing a missing jaw. In 1989 Hidalgo from Memorial Sloan Kettering out of the plastic surgery world, described the use of a fibula flap for jaw reconstruction but mentioned in that paper that it was not advised to replace missing teeth with dental implants because it was felt that that would be deleterious, or it could damage the blood supply to the flap. He also felt that using skin from that particular flap could cause long-term wound breakdown and that the flap would be unreliable.

Well a few years later, people began putting dental implants into the fibula. But that would take many, many months and sometimes over a year and that was complicated by the fact that patients needed radiation therapy and that patients many times couldn’t afford the implants. Well now at UAB, our patients who have head and neck cancer and particular jaw cancers can have the implants with the use of 3-D imaging and 3-D surgical navigation that can place the implants into the leg bone, the prosthodontist comes in and puts the teeth, the temporary prosthesis at the leg. I then divide the blood vessels and transfer the leg, the metal plate, the implants and the teeth up to the jaw, hold it in place with plates and screws, reconnect the blood supply under the microscope; and that patient truly has a total jaw reconstruction done in one day.

And that is only available because of all of the different technological advances that have been made over the past 20 years. and it’s just a matter of taking all of that information and combining it. So, I think sometimes surgeons are – we have to be innovators but more than that, we have to be assimilators of data and combine different thoughts and cross disciplines, cross dentistry, cross oral and maxillofacial surgery, otolaryngology, plastic surgery and use all of these different backgrounds to come together with a very good product for our patient. Very good outcome.

Host: That is so cool. Dr. Morlandt, what you just described is absolutely amazing. So, as we wrap up where do you see this field and the technology going? I mean wow, what you’ve described to us today sounds so advanced and of course it can get more advanced. Where do you see it going in the next five to ten years?

Dr. Morlandt: Well it would be great if we got to a time where we didn’t have to do head and neck cancer surgery. So, our utility is as ablative surgeons, could be smaller and I think that is coming in terms of the medical oncology research and some of the molecular work that’s being done in radiation oncology.

In terms of reconstruction and helping these patients function because to be honest, we don’t really help patients long-term is we have – if they survive but they can’t speak, chew or swallow. And so, we want to make sure we optimize their function. But I could envision a time where we are not – we don’t have to harvest someone’s own bone, muscle and soft tissue to reconstruct the face where we can use a scaffold and the scaffold can be populated with pluripotent stem cells and be used with the right combination of growth factors and cell signaling molecules can be used to generate some bone and soft tissue that can then transferred to that patient.

A version of that is already being done where we will prelaminate or prefabricate a flap where I may take some cartilage or some mucosa or some skin and place that just on top of the fibula bone and then when the – or under the radio forearm distribution and then when that’s transferred; you have some flap component that’s already been sort of repaired. But that still requires a second donor site surgery. So, I can envision a time where we are creating smaller wounds and we have a need for smaller reconstruction and that ultimately impacts patient’s quality of life, their length of stay in the hospital, their risk of surgical wounds and infection and all of the complications that are associated with these operations we do.

So, I think we are just getting more and more streamlined as time goes on.

Host: Absolutely fascinating. Thank you so much for joining us today and sharing your incredible expertise explaining all the technology that’s available now for these types of cancers. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for tuning in.