H+N Surgical Oncology

[laserzpewpew]

I was taking a break from studying so I decided to post this question that's been on the back of my mind for a while now.

I've recently developed an interest in palliative care and pain management, and would like my future career to involve that to some degree. I know that doing a surgical oncology fellowship after a general surgery residency and becoming a surgical oncologist involves quite a bit of palliative care. However, I am quite interested in the craniofacial region and was initially planning on pursuing maxillofacial surgery (OMFS). However, I've recently begun considering going into ENT and doing a Head and Neck Surgical Oncology fellowship after. Now I do know that maxillofacial surgeons can go on to do H+N oncology fellowships, but I was wondering if going the ENT route will be better.

So, I was hoping someone would be able to comment on the degree of palliative care involved in OMFS H+N surgical oncology, versus ENT H+N surgical oncology, versus General Surgical Oncology.

Thanks.

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[VisionaryTics]

Are you interested in surgery or pain management/palliative care?

Ever thought about a pain fellowship? I think you can do it from anesthesia or neurology.

Also, OMFS is a dental specialty.

 

[laserzpewpew]

Are you interested in surgery or pain management/palliative care?

Ever thought about a pain fellowship? I think you can do it from anesthesia or neurology.

Also, OMFS is a dental specialty.

I'm interested in both. Surgery more though.

 

[OtoHNS]

I was taking a break from studying so I decided to post this question that's been on the back of my mind for a while now.

I've recently developed an interest in palliative care and pain management, and would like my future career to involve that to some degree. I know that doing a surgical oncology fellowship after a general surgery residency and becoming a surgical oncologist involves quite a bit of palliative care. However, I am quite interested in the craniofacial region and was initially planning on pursuing maxillofacial surgery (OMFS). However, I've recently begun considering going into ENT and doing a Head and Neck Surgical Oncology fellowship after. Now I do know that maxillofacial surgeons can go on to do H+N oncology fellowships, but I was wondering if going the ENT route will be better.

So, I was hoping someone would be able to comment on the degree of palliative care involved in OMFS H+N surgical oncology, versus ENT H+N surgical oncology, versus General Surgical Oncology.

Thanks.

If you are interested in H+N oncology, ENT is definitely the way to go and has been the dominant specialty to care for surgical issues in H+N CA patients for the past couple decades. The exception would be thyroid cancers, which are a lot more frequently seen by general surgeons and surgical oncologists.

There are very few OMFS programs that do any real H+N oncology. The OMFS chief residents at my residency institution would spend a month on our service to basically assist on cancer cases since they had no other exposure to it and it's tested on their boards.

Almost all ENT programs will prepare you well for H+N ablative surgery (i.e. taking the tumor out). H+N oncology fellowships are primarily for learning microvascular reconstructive techniques, though also you would get more exposure to complex tumors and less common locations for surgery (skull base, parapharyngeal space).

As far as palliation and pain management, we would typically refer appropriate patients to palliative care/pain clinic. This would include terminal patients who had failed surgery or chemo/XRT or patients who had a successful response to treatment but continued to have chronic need for opiates. We would of course be available for palliative procedures (trachs, control of bleeding, etc) if needed. Other institutions may take a more active role in palliative care, but honestly you have enough to do already and palliative specialists are better at it because it's their main focus.

 

[Leforte]

Agree with OtoHNS except for the issue of thyroid CA - I think that it is really regionally dependent on whether a GS vs ENT. There have been a few studies looking at differences in outcomes, which appear to be equal, though technique is different.

http://www.ncbi.nlm.nih.gov/pubmed/17047499

It is more developing a niche for this type of surgery, and having a sufficiently high volume to get the best outcomes. I believe there was an article recently that indicated the best outcomes were for surgeons (GS or ENT or other) who were doing > 50 per year, although I'd have to go back to look it up.

In anycase, while there are multiple pathways to get to H&N oncology - I would suggest the ENT pathway (although I am biased, of course) as this offers the most comprehensive training in residency and would allow you to focus on microvascular in your fellowship. You would get the benefit of different techniques from your attendings in residency for necks, SNLN Bx, loco regional flaps - as well as the methods (which may be different) at your fellowship.

 

[OtoHNS]

Agree with OtoHNS except for the issue of thyroid CA - I think that it is really regionally dependent on whether a GS vs ENT. There have been a few studies looking at differences in outcomes, which appear to be equal, though technique is different.

http://www.ncbi.nlm.nih.gov/pubmed/17047499

It is more developing a niche for this type of surgery, and having a sufficiently high volume to get the best outcomes. I believe there was an article recently that indicated the best outcomes were for surgeons (GS or ENT or other) who were doing > 50 per year, although I'd have to go back to look it up.

In anycase, while there are multiple pathways to get to H&N oncology - I would suggest the ENT pathway (although I am biased, of course) as this offers the most comprehensive training in residency and would allow you to focus on microvascular in your fellowship. You would get the benefit of different techniques from your attendings in residency for necks, SNLN Bx, loco regional flaps - as well as the methods (which may be different) at your fellowship.

Agree fully with this. I was a bit vague above about thyroid surgeries. It's really dependent almost entirely on referral patterns as to whether ENT or Gen Surg/Surg Onc dominates in a particular city or health system. At my residency, endocrine traditionally referred all thyroid/parathyroid cases to a particular surgical oncologist, so it was always akin to pulling teeth to get them to send any to us. That being said, I still graduated with ~25 thyroids under my belt. At a endocrine heavy ENT program, though, you could end up with A LOT more than that.

So, the moral is that you will likely get trained adequately in thyroid surgery whether you do ENT or Gen Surgery.

For other H+N cancers, there are VERY FEW (?No) Gen Surg residencies that will prepare you as well as ANY ENT residency to care for these patients.

 

[DREDAY]

I was taking a break from studying so I decided to post this question that's been on the back of my mind for a while now.

I've recently developed an interest in palliative care and pain management, and would like my future career to involve that to some degree. I know that doing a surgical oncology fellowship after a general surgery residency and becoming a surgical oncologist involves quite a bit of palliative care. However, I am quite interested in the craniofacial region and was initially planning on pursuing maxillofacial surgery (OMFS). However, I've recently begun considering going into ENT and doing a Head and Neck Surgical Oncology fellowship after. Now I do know that maxillofacial surgeons can go on to do H+N oncology fellowships, but I was wondering if going the ENT route will be better.

So, I was hoping someone would be able to comment on the degree of palliative care involved in OMFS H+N surgical oncology, versus ENT H+N surgical oncology, versus General Surgical Oncology.

Thanks.

You can achieve your desire of going into surgical oncology by going either route. I obviously am biased because I am an OMFS resident interested in oncology myself. While there is overlap between the ENT and the OMFS oncological surgeons, there are some differences which are primarily dictated by the approach of training. Most OMFS oncology trained surgeons will primarily perform oral and facial cancers. Very few will operate on laryngeal cancers or skull base tumors.

The advantage of an OMFS trained oncological surgeon is that after resecting a mandible or maxilla, not only will they be able to reconstruct it, but they will also be able to restore oral function by placing the dental implants. This is something that ENT surgeons do not typically do.

Here is a list of a places where OMFS H+N oncological surgeons are operating: LSU Shereveport, LSU New orleans, Jasksonville, Oregon, Washington U, U Michigan, Jackson memorial, Gainsville, University of Maryland, NYU, North Dakota, Un of Minesota, Fresno, alabama.... im sure there are more that I am missing.

 

[earboy]

There are no oncologic OMFS surgeons at Washu whatsoever. I am an ENT chief resident there and know the OMFS guys quite well. I have never worked with an OMFS who does cancer but I'm sure it does happen at some institutions. As for reconstructing maxillofacial and mandibular defects, we do just fine on our own. That's the way it has always been. OMFS will sometimes place prosthetic joints for tumors involving the TMJ (ameloblastoma) patients, but that's about it here.

To the OP, do not take the hellish path of head and neck training in order to practice palliative medicine. There are palliative specialists who do this as a career. Many of your H&N cancer patients will die, unfortunately, but palliation will be reserved to those folks who specialize in that area.

 

[Pir8DeacDoc]

The advantage of an OMFS trained oncological surgeon is that after resecting a mandible or maxilla, not only will they be able to reconstruct it, but they will also be able to restore oral function by placing the dental implants. This is something that ENT surgeons do not typically do.
.

Just as the above poster ear boy mentioned, we do our own recon too (ENT). Maybe your head and neck cancer patients are different than ours but not many people want to put implants into a fibula that's radiated. Not to mention no patient I've ever taken care of can afford dental implants. Most of them haven't had teeth for years...Sounds nice in theory but there's little practical value. What would be helpful is a great prosthodontist, we could use one of those.

 

[DREDAY]

There are no oncologic OMFS surgeons at Washu whatsoever. I am an ENT chief resident there and know the OMFS guys quite well. I have never worked with an OMFS who does cancer but I'm sure it does happen at some institutions. As for reconstructing maxillofacial and mandibular defects, we do just fine on our own. That's the way it has always been. OMFS will sometimes place prosthetic joints for tumors involving the TMJ (ameloblastoma) patients, but that's about it here.

To the OP, do not take the hellish path of head and neck training in order to practice palliative medicine. There are palliative specialists who do this as a career. Many of your H&N cancer patients will die, unfortunately, but palliation will be reserved to those folks who specialize in that area.

Sorry, I meant University of Washington.

 

[DREDAY]

Just as the above poster ear boy mentioned, we do our own recon too (ENT). Maybe your head and neck cancer patients are different than ours but not many people want to put implants into a fibula that's radiated. Not to mention no patient I've ever taken care of can afford dental implants. Most of them haven't had teeth for years...Sounds nice in theory but there's little practical value. What would be helpful is a great prosthodontist, we could use one of those.

Usually the dentures in large reconstructive cases need to be supported by implants. Even the best prosthodontist will usually not get a good result using a non-implant supported denture due to the minimal vestibule that often results after reconstructions with a fibula. For total maxillectomy, or hemimaxillectomy with irradiated maxilla, you can always do zygomaticus implants which in some cases are covered by insurance.


And yes you can put implants on irradiated fibulas:

http://www.ncbi.nlm.nih.gov/pubmed/21371725

http://www.ncbi.nlm.nih.gov/pubmed/20171471

 

[blue2000]

Sorry, I meant University of Washington.

Just to clarify -- if you mean Neil Futran at UW, he is a DMD/MD who did a full oto residency. He does big cancer operations, but it's kind of inaccurate to call him an OMFS who does cancer surgery. I'm not sure that OMFS does much cancer operating at UW. They do complex facial reconstruction, especially at Harborview in the trauma population, but to my knowledge they aren't doing big facial whacks.

It'd be crazy to do a surgical field if you actually wanted to do palliative care. Not to say that surgeons don't interact with palliative care ALOT, just that what we do and what they do are complementary without a ton of overlap.

 

[DREDAY]

Just to clarify -- if you mean Neil Futran at UW, he is a DMD/MD who did a full oto residency. He does big cancer operations, but it's kind of inaccurate to call him an OMFS who does cancer surgery. I'm not sure that OMFS does much cancer operating at UW. They do complex facial reconstruction, especially at Harborview in the trauma population, but to my knowledge they aren't doing big facial whacks.

It'd be crazy to do a surgical field if you actually wanted to do palliative care. Not to say that surgeons don't interact with palliative care ALOT, just that what we do and what they do are complementary without a ton of overlap.

No I was talking about Jasjit Dhillon. She is new at UW.

 

[ThePursuit]

This is actually a really interesting post. The idea of implants s/p fibula flap is interesting.

 

[Pir8DeacDoc]

Usually the dentures in large reconstructive cases need to be supported by implants. Even the best prosthodontist will usually not get a good result using a non-implant supported denture due to the minimal vestibule that often results after reconstructions with a fibula. For total maxillectomy, or hemimaxillectomy with irradiated maxilla, you can always do zygomaticus implants which in some cases are covered by insurance.


And yes you can put implants on irradiated fibulas:

http://www.ncbi.nlm.nih.gov/pubmed/21371725

http://www.ncbi.nlm.nih.gov/pubmed/20171471

Interesting articles. Thanks for sharing them.

I still contend that a very small percentage of head and neck patients are even candidates for this type of treatment. Dentists have insulated themselves against taking care of people without means, so that's pretty much all head and neck cancer patients. Also, one of the articles mentions the Marx protocol. You can bet no patient can afford hyperbaric therapy followed by dental implants. Just not feasible. Possible in theory but not in practicality.

My comments about prosthodontists was specially directed towards problem we face with maxillectomy defects. We don't have anyone even close to locally and it's a huge problem. We tend to use pedicled submental flaps to obliterate the cavities, but in many cases I think a well fit obturator would suffice.

 

[Fah-Q]

So, trade laryngeal and skull base training for implants? No thanks. I'll do the resection and the flap. I'll then call my buddy in to put a few implants in the fibula. I'll be there for 8-12 hours. He'll be there for an hour and make more for the doing the implants than I will for the whole rest of the case. Why would an OMFS ever want to do the whole thing?? Just shuck some teeth and drive your Ferrari home by 5.

The OMFS volume at Michigan is not sufficient for head and neck training. I don't know about the other programs.

ENT is the way to go if you want head and neck training. If you want to be in palliative care then there is no reason to pursue surgical training. Go into medicine --> med onc. Or you could go ane$the$ia --> pain management.

 

[OtoHNS]

Interesting articles. Thanks for sharing them.

I still contend that a very small percentage of head and neck patients are even candidates for this type of treatment. Dentists have insulated themselves against taking care of people without means, so that's pretty much all head and neck cancer patients. Also, one of the articles mentions the Marx protocol. You can bet no patient can afford hyperbaric therapy followed by dental implants. Just not feasible. Possible in theory but not in practicality.

My comments about prosthodontists was specially directed towards problem we face with maxillectomy defects. We don't have anyone even close to locally and it's a huge problem. We tend to use pedicled submental flaps to obliterate the cavities, but in many cases I think a well fit obturator would suffice.

I think at some of the big free flap factories where they're doing 1-2 fibulas every week see more of the dental implants. I would agree that the typical patient population at my residency were not good candidates at all.

Agree totally about good prosthodontists, especially for maxillectomy defects. A good obturator works amazingly well.

As far as the OMFS vs ENT debate, I still maintain that ENT is a much easier route to learn H+N oncologic surgery. I love my OMFS guys (and girls) though, so I'm glad this thread isn't turning into a flame war. We can leave that for the general surgeons, LOL.

 

[DREDAY]

So, trade laryngeal and skull base training for implants? No thanks. I'll do the resection and the flap. I'll then call my buddy in to put a few implants in the fibula. I'll be there for 8-12 hours. He'll be there for an hour and make more for the doing the implants than I will for the whole rest of the case. Why would an OMFS ever want to do the whole thing?? Just shuck some teeth and drive your Ferrari home by 5.

The OMFS volume at Michigan is not sufficient for head and neck training. I don't know about the other programs.

ENT is the way to go if you want head and neck training. If you want to be in palliative care then there is no reason to pursue surgical training. Go into medicine --> med onc. Or you could go ane$the$ia --> pain management.

OMFS who pursue Oncology training do so because they are passionate about it. It is obviously not about the money. Driving a Ferrari is not a priority.

The volume of cancer and reconstructive surgeries that most OMFS receive during residency is not sufficient for them to perform those surgeries immediately after residency. OMFS who perform oncological surgery do so after a 1-2 year fellowship in H+N oncology and reconstruction.

Like I said before, there is more than one way to skin a cat. You can pursue H+N training from and OMFS or ENT route.

 

[Fah-Q]

OMFS who pursue Oncology training do so because they are passionate about it. It is obviously not about the money. Driving a Ferrari is not a priority.

The volume of cancer and reconstructive surgeries that most OMFS receive during residency is not sufficient for them to perform those surgeries immediately after residency. OMFS who perform oncological surgery do so after a 1-2 year fellowship in H+N oncology and reconstruction.

Like I said before, there is more than one way to skin a cat. You can pursue H+N training from and OMFS or ENT route.

OK. Do what you are passionate about. Just about every OMFS I know is passionate about cash and easy living. I just wish someone told me about dental school before I signed up for medical school.

The volume issue I mentioned at Michigan is still relevant. You would need about 4 years of fellowship there to get enough volume. Hopefully the other fellowships offered through OMFS have much better volume.

 

[capnamerica]

Would someone mind posting a couple of journals I could peruse about H+N surgical oncology? I've developed an interest in this field over the years, and would like to keep up with the current literature. Thanks.

 

[OtoHNS]

Would someone mind posting a couple of journals I could peruse about H+N surgical oncology? I've developed an interest in this field over the years, and would like to keep up with the current literature. Thanks.

The literature may be kind of spread out since several different specialties care for these patients.

On the ENT side, your best bets for quality articles would be Otolaryngology- Head and Neck Surgery (aka "The White journal") and Laryngoscope. Also will be some stuff in Archives, Annals, ENT Journal, etc.

 

[rmm262002]

Also "Head and Neck"