Brief Answer: As below: Detailed Answer: Hi, Thank you for your query. 1. Dr XXXXXXX Pradhan is one of the foremost Cancer Surgeons in India and probably the World. Head & Neck Cancer has a propensity for multiple sites and it is unfortunate that the cancer has recurred thrice. 2. If you can provide the exact details of the cancer at various stages (1995, 2009 and 2013) along with the detailed operative notes, it may be possible to pinpoint why his symptoms originated. Otherwise, the possibilities are: a. The severe headache: The face and anterior scalp is innervated by the Trigeminal (Fifth Cranial) Nerve which travels near the eye, deep in the face before branching out across the face. It is possible that this signifies a spread of the tumor, excessive scarring after three surgeries in the same area or a neuroma formed at the cut ends of the branches after the various surgeries. This pain may be have to managed with neurogenic pain killers such as amitriptyline, carbamazepine, gabapentin or pregabalin. b. Coughing while eating: If the coughing is more with solids, the throat and larynx must be examined for any mass. If the coughing is more with liquids, it may signify a neurogenic problem or the involvement of the lower cranial nerves by a spreading tumor. If he is aspirating liquids into the airway, while eating, thickening the feeds will help. c. PET (Positron Emission Tomography) Scanning is a Scanning technique where a radioactive labelled marker, most commonly 18, FDG (Fluorodeoxyglucose) is used routinely now to look for residual or recurrent cancer. It is expensive because of the radioactive marker. d. The drooping of the left eye is either because of damage to the muscle or nerve of the eyelid (Occulomotor- third Cranial Nerve). This may be due to extensive surgery or spread of the tumor, either locally or into the neck (Horner's Syndrome). e. He now has nasal regurgitation either due to a connection between the palate and the nose or paralysis of the soft palate. How is his voice? 3. I would recommend the following: a. Seeing the involvement of multiple Cranial Nerves, it is better to get the PET CT done as soon as possible. This may explain how the pain, drooping eye, coughing, nasal regurgitation are related. b. Use of a Feeding tube. c. Appropriate medication. Chemotherapy and Radiotherapy need to be considered. Is there any past use of these? d. It is difficult to treat the drooping eyelid. Physiotherapy and biofeedback will help. e. It might be worthwhile to look for any Circulating Tumor Cells (CTC). Visit the website of Datar Genetics limited. If you have any further questions, I will be available to answer them. Regards.

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Brief Answer: As below: Detailed Answer: Hi, Thank you for writing back. 1. From the PET CT Report, he now has both local recurrence and neck metastasis. 2. It is important for you to consult both Dr. XXXXXXX Pradhan and Dr. Advani (The Oncologist). 3. Get an FNAC of the lymph node and a biopsy from the mouth to confirm the presence of any tumor and the type. Tissue diagnosis is a prerequisite for any further treatment and the Surgeon is required to do this. 4. Get a Videolaryngoscopy done to check the cause of worsening voice. 5. Chemotherapy and Radiotherapy are options to avoid another operation. This is where the Oncologist is needed. No further treatment is also an option. however he will require palliative treatment for the pain and a feeding tube / gastrostomy for for the swallowing difficulty. Hope I have answered your query. If you have any follow up queries I will be available to answer them. Regards

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Brief Answer: As below: Detailed Answer: Hi, Thank you for writing back. 1. Gefitinib is a inhibitor of Epidermal Growth Factor Receptor (EGFR). It is given on the expectation that most Head & Neck Cancers have over expression of the EGFR's. 2. Hence gefitinib will only be effective in tumors positive for EGFR. Therfore it makes sense to test a tumor biopsy for EGFR. This will help predict whether gefitinib will be worthwhile. 3. Hence I would again recommend that you get a Pharmacogenetic Oncology Plus Panel Test done through labs such as SRL or Datar Genetics Limited. It will be worth the effort. 4. Even if gefitinib is effective, the mean life expectancy will increase by a few months on gefetinib alone. This is where the Oncologist can add medicines such as Methotrexate among others to further increase the effectiveness of gefitinib. 5. Pain relief and Feeding are also important for Quality of Life. I must emphasize that with such spread of the cancer, you are now looking at only palliative (and not curative) care. Hope I have answered your query. If you have any follow up queries I will be available to answer them. Regards

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Brief Answer: Admit if possible. Detailed Answer: Hi, Thank you for writing back. 1. I would recommend that you admit him immediately. 2. Since he cannot swallow, it will be difficult for you to give him adequate fluids, glucose or pain killers orally. 3. A feeding tube is a very simple option in a hospital. It will also be easy to administer the fluids, glucose and painkillers intravenously. 4. If possible (and if he is not coughing / aspirating fluid into his lungs), give him sips of water mixed with regular Glucon-D. You may try liquid Combiflam 10 ml at a time thrice a day for a couple of days. (it may lead to gastritis soon as he cannot eat). What is his weight? I hope that I have answered your query. If you have any further questions, I will be available to answer them. Regards.

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Brief Answer: As below: Detailed Answer: Hi, Thank you for writing back. 1. Since he is aspirating into his lungs, you need to get him admitted and start feeds with feeding tube or a feeding gastrostomy. This will avoid fluid entering the lungs. 2. The exact dose of intravenous glucose, fluids and painkillers should be decided by your physician as per the requirement, input / output and pain threshold levels. 3. you may discontinue Gefitinib at present. I hope that I have answered your query. If you have any further questions, I will be available to answer them. Regards.

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