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Melanie Cole (Host):  Today we’re talking to Dr. Peter Dziegielewski. He’s an Associate Professor and Chief of the Division of Head and Neck Oncologic and Microvascular Reconstructive Surgery at the University of Florida. And he practices at UF Health Shands Hospital in Gainesville. Our topic today, is robotic surgery in head and neck cancer treatment. Dr. DZ, thank you so much for joining us today. I’d like to just set the stage for other providers. Explain a little bit about the prevalence of head and neck cancer and some common conditions and factors that can lead to it.

Peter Dziegielewski, MD (Guest):  The fifth or sixth most common cancer in the United States depending on the year. It accounts for probably less than 5% of all cancers but the incidence of it has increased in the last two decades and that’s mainly because of the incidence of the human papilloma virus and infections of the oropharynx or the tonsils and base of the tongue. So, it’s not the most common cancer, but it’s certainly one that’s becoming much more known and talked about in the news.

Host:  Then let’s talk about the clinical presentation and how important early diagnosis is as being crucial to improve outcome prediction.

Dr. Dziegielewski:  So, head and neck cancers encompass the cancers of the head and neck including the oral cavity. So, sites like the tongue, the forward mouth, the jaw, oropharynx, so cancers of the tonsils and base of the tongue. Also cancers of the larynx, the hypopharynx and so, depending on where the cancer starts will dictate how the patient may present. So, this can present as a sore or an ulcer inside the mouth that’s not going away after a few weeks. Patients can present with a growth inside the mouth or the throat. Some will present with just a neck mass as the first place that these cancers tend to spread to are lymph nodes in the neck.

And then others can have more extreme presentations such as difficulty swallowing, difficulty breathing, change in voice, or unexplained weightloss. So, there’s kind of a spectrum of presentations that patients may come to their doctor with. Early diagnosis is absolutely crucial because the earlier you can diagnose one of these cancers, the better the patient’s survival. And because these cancers are in such a very intricate area of the body; the treatment can have certainly devastating affects on the patient. And the smaller the cancer, the earlier the stage; the less side effects patients are going to have from treatment. So, ideally, you catch the cancer early; you can save the patient’s life and still maintain an excellent quality of life and functional outcomes.

Host:  Well thank you for that Dr. DZ. So, due to the sensitivity of this type of cancer and it’s intricate nature; tell us about some of the advancements that have been made in the treatment as far as minimally invasive technology, robotics, that could allow surgeons to access hard to reach areas of the mouth and throat.

Dr. Dziegielewski:  So, one of the technologies that’s developed over the last 15 years is robotic surgery. And in the past, whenever we’d have to cut out a tumor in the back of the mouth or the throat; we would have to do maximally invasive approaches meaning we would have to cut the patient’s jaw open and cut through their lip and get to the cancer, remove it and then reconstruct the area. A lot of these surgeries would take a dozen hours or so to finish and patients would have very morbid long-term affects from this including difficulty swallowing, speaking and poor quality of life.

Now with the use of the robot; what we are able to do is put a camera in the patient’s mouth as well as two robotic arms that we can control remotely from another console in the room. And by doing this, we can get into the back of the mouth and the back of the throat and cut out and resect tumors that we otherwise could not get to very easily. So, this allows us to preserve normal structures such as parts of the tongue, the muscles in the mouth and tongue as well as the nerves in that area and so this allows patients to heal quicker and return to functions of swallowing and speech which is something, they may not have been able to do in the past.

Also, it’s given us an opportunity to treat certain tumors such as those of the tonsils and the bade of the tongue surgically whereas before, we would rely much more on radiation therapy which can have a lot more long-term side effects. So, the idea here is that we want to minimize patients’ long-term side effects by minimizing exposure to more toxic treatments such as high doses of radiation and chemotherapy. So, with the use of robotic surgery, we are able to give the patients more options with similar or better cure rates and much less toxicity in the future.

Host:  For the surgeons, the benefits. How is endoscopic instrumentation coupled with improved intraoperative imaging helping you to reach those areas? Speak about the benefits for the surgeon.

Dr. Dziegielewski:  The robotic instrumentation gives us seven degrees of freedom. We can move the robotic instruments in every direction that our wrists and our fingers can move. And we can adjust how much movement we want in those instruments. We can magnify our movements, or we can minimize them so that we can eliminate hand tremor, or we can make the robotic instruments move quicker, faster depending on the movements we need. And we couple that with high definition endoscopes, and we can get a very close up view of the anatomy that now we are operating around. So, this lets us identify structures much sooner than we would normally so we can preserve normal anatomy. Also it lets us get a great view of the tumor so we can stay away from the margins of the tumor and it’s just a much more comfortable for us to operate in small areas by essentially making ourselves down to the size of a nickel or smaller and being able to operate in a very small area. And that’s what the high definition cameras let us do.

Host:  Technology is amazing for what you’re doing and what an exciting time for the advancements in head and neck cancer. You mentioned the daily lives of patients because of this type of cancer whether it’s eating, self-esteem, speech, appearance; all of those things. Speak for us Dr. DZ about after surgery and the after care cancer team and the multidisciplinary approach that might be needed.

Dr. Dziegielewski:  So here at UF Health Shands Hospital, we have a very large multidisciplinary team for patients undergoing head and neck cancer treatment. And that all starts with our surgical team. so, we have surgeons, fellows and residents looking after patients and then after the patients get through surgery, we have subspecialized nurses and nurse practitioners, nurse navigators who help patients get through their entire treatment plan. Because a lot of these patients will need additional treatment in the future and that may be radiation or chemotherapy and so we have physicians that treat patients based on those treatment modalities. And then after patients go through all of that; their treatment is not done. Now they have to recover. And so that involves intensive speech and swallowing therapy, physical therapy, consultations with the dietician, consultations with dentists and prosthodontists and so there’s a huge team looking after patients to try to get them back to looking as normal as possible, feeling as normal as possible and functioning as normal as possible.

And that functioning can be very simple things such as being able to lift one’s arms above one’s head to wash your hair or comb your hair to being able to eat out in public, to being able to speak over the phone. Lots of things that we just take for granted that are completely changed with these patients forever. And so, there is a long term dedication of these patients need to be part of and that’s not just their treatment but their long term rehabilitation. And here at UF Health Shands, we have a functional outcomes clinic where we follow our patients long-term and try to improve all of these functions that we possibly can. The earlier we do that, the better the patients do for the rest of their lives.

Host:  Well that certainly is a comprehensive approach. Tell us a little bit about current research. What does it indicate for future developments in treatments? Give us a little blueprint and while you’re doing that, are there some treatments or research that you’re doing at UF Health Shands Hospital that other physicians may not be aware of?

Dr. Dziegielewski:  So, a lot of research that we’re doing at UF Health Shands Hospital involves clinical research as well as basic science research. So, on the clinical sides of things; we’re looking at utilizing newer technologies to improve reconstruction in head and next surgery. So, for example, one of the things that we do is surgical planning on the computer where we can take a patient’s CT scan and we can upload that and get a three dimensional image of their craniofacial skeleton and then we can also take a image of another part of their body such as a bone in their leg, like the fibula or the scapula from their back and we can plan exactly how we are going to remove their tumor.

So, if we are going to cut out part of their jaw, we can plan that exactly, what we are going to do on the computer. And then we can also plan the reconstruction on the computer. And from that, we can print out a three dimensional model of the patient’s jaw with our reconstructive plan on that. And we can also print off cut guides that we can use in the OR so that we can make the exact cuts we’re planning to make. So, we can put those onto the jaw, cut out the cancer; we can put the cut guides on the leg bone, the fibula for example, make our cuts on there and put dental implants into the bone at the same time and then we can do the whole reconstruction on the same day of surgery.

And then once the patients heal, we can uncover their dental implants and give them teeth. Which is something we weren’t able to do ten to twenty years ago and this is something that we are starting to use more and more and more. And almost every patient that goes through one of these operations, we’re able to do this virtual planning on ahead of time. And what that means for the patient is more precise reconstructions, faster OR times and by decreasing the patient’s time under anesthesia; we help them heal faster and that decreases their chance of complications. And what this translate to in the short term is quicker recovery, quicker time to additional treatments and then what it translates to in the long-term is just better appearance and better functional outcomes which essentially translates to better quality of life in the future.

So, that’s one of the big areas that we’re focusing on. Other areas in the basic science domain include research on using nanoparticles in the treatment of head and neck cancers and developing targeted treatments. Over the last ten years or so, there have been newer and newer technologies being developed to promote drugs that attack various cancer targets at the molecular level. And it seems that almost every month a new target is being developed and we are very involved in developing tumor vaccination treatments and nanoparticle treatments that focus on attacking those molecular markers in head and neck cancers.

And the goal is to develop drugs that eventually would be able to fight head and neck cancer without having to use any toxic treatments. So, we are working on that. We have a lab that’s dedicated to that. And that’s one of the other exciting areas that we are focusing on.

Host:  Well thank you for that answer. So, interesting. As we wrap up, tell other physicians what you’d like them to know about head and neck cancer surgery, reconstruction and when you feel it’s important that they refer to the specialists at UF Health Shands Hospital.

Dr. Dziegielewski:  So, I think one of the biggest points is that head and neck cancer is a very potentially devastating disease for patients. However, we have come a very long way in the last 30 years. Surgeries are not nearly as disfiguring and dysfunctioning as they once were. We have a lot of technology that’s enabled us to use minimally invasive methods to remove cancers and much more improved technologies to reconstruct patients so that they can function afterwards. And one of the most important things is that patients see someone who is the leader of the head and neck cancer team at their institution and that’s often going to be a surgeon who can direct the patient to the appropriate treatment.

One of the things that we really value at UF Health Shands is a multidisciplinary comprehensive approach and that all starts at our head and neck cancer tumor board. And so patients are often referred to myself or one of my colleagues who is a surgeon and we bring the case to our tumor board and we discuss the case and we plan what we think will be the best option for the patients to maximize their survival and balance that with quality of life and functional outcomes.

And so, I think one of the most important things is making sure that the patients get referred to the appropriate clinic and to the appropriate person who is an expert in head and neck cancer. This isn’t one of those disease types that can be dealt with just by anybody. These patients really need a whole team looking after them. And so, here at UF Health Shands, that starts with myself or one of my colleagues a head and neck cancer surgeon.

Host:  Wow, such great information. What a fascinating topic. Dr. DZ, thank you so much for joining us today and sharing your expertise. That concludes this episode of UF Health MedEd Cast with UF Health Shands Hospital. To learn more about cancer clinical trials available at the UF Health Cancer Center, please visit www.ufhealth.org/navigator. You can also learn more about this and other healthcare topics at UF Health Shands Hospital if you visit www.ufhealth.org/medmatters to get connected with one of our providers. For more health tips and updates on the latest medical advancements and breakthroughs please follow us your social channels. I’m Melanie Cole.