Maxfacts

A brief summary of the role of oral and maxillofacial surgery in the management of metastatic malignancies appears to be a straightforward narrative, describing a situation where maxillofacial surgery

• supports the treatment / management of distant metastases from solid tumours elsewhere in the body that manifest in the head & neck region, similar to the maxillofacial surgery support role in the management and treatment of haematological malignancies;
• manages and treats regional (neck) and distant (below the line of the collar bone) metastases originating from head & neck malignancies.

These two arms of activity include all aspects of maxillofacial surgery when confronted with metastatic disease. Another way to briefly summarise the role of maxillofacial surgery in these circumstances would be to simply say that the role is to manage disease progression.

However, what is invisible in these brief summaries are the numerous difficulties encountered when having to deal with metastatic disease. These include diagnostic challenges associated with previous treatment(s), difficult decisions about the best treatment options (which are individually different), difficult conversations and processes when faced with disease progression, tumour recurrence or a second local primary tumour (or combinations of these conditions), sometimes metastatic disease may well be an issue from the initial diagnosis because head and neck malignancies are often diagnosed and identified at an advanced stage. It is common that important decisions have to be made at a time of serious distress, and a holistic approach including mental health issues and support is key to arrive at sound decisions, care and treatment planning.

Treatment planning for metastatic disease does need to include decisions about treatment with curative intent, or opting for palliative treatment modalities. The available treatment modalities are broadly the same as those on offer for initial treatment of a primary tumour and include

• (salvage) surgery;
• radiotherapy, possibly combined with some form(s) of
• chemotherapy;
• increasingly immunotherapies are being used in the palliative treatment of some head & neck malignancies.

It is important to understand that a decision for or against treatment option(s) is a highly individual matter, for technical reasons as well as for reasons of patient priorities and preferences. It is important to understand that broader issues of metastasis in maxillofacial malignancies are slightly different from most other malignancies, because of the special anatomical conditions in the head & neck region. It is further important to understand the palliative nature of some treatment schemes, even if major surgery may be involved. One should not be tempted to think that interventions other than supportive care are always offered / carried out with curative intent.

The following pages try to help with making difficult treatment decisions. First of all, honest and in-depth communication between all involved is of fundamental importance to arrive at the individually best decision(s). Equally important is proper knowledge and understanding of the conditions and corresponding, realistic treatment options. These aspects are discussed in more detail on the following pages.