Lateral pharyngotomy approach in the treatment of oropharyngeal carcinoma

Functional Outcomes After Transoral Plus Lateral Pharyngotomy Approach for Advanced Oral and Oropharyngeal Tumors

Objective

The aim of this study was to evaluate our institutional experience with the combined transoral plus lateral pharyngotomy (TO+LP) approach in a subset of patients with advanced or recurrent oral and oropharyngeal malignancy.

Study Design

A retrospective study of procedures utilizing TO+LP for cancer resection between January 2007 and July 2019.

Setting

Tertiary academic medical center.

Methods

Thirty-one patients underwent a TO+LP approach for the resection of oral and oropharyngeal tumors. Functional and oncologic outcomes were analyzed.

Results

Eighteen (58.1%) patients were treated with TO+LP for recurrent disease. Twenty-nine required free tissue transfer and 2 (6.5%) had positive margins. The median time to decannulation was 22 days (range 6-100 days). Thirteen (41.9%) patients still required enteral feeding at their most recent follow-up. Patients without a history of prior radiation were decannulated sooner (p = .009) and were less likely to require enteral feeding at the first postoperative follow-up (p = .034) than those who had prior head and neck radiotherapy.

Conclusion

A TO+LP approach can be used to achieve good functional and oncologic results for selected patients with advanced or recurrent oral and oropharyngeal cancer when minimally invasive options such as transoral robotic surgery, transoral laser microsurgery, or radiotherapy are not possible.

Treatment Options in Early Stage (Stage I and II) of Oropharyngeal Cancer: A Narrative Review

OBJECTIVE

to show an overview on the treatments' options for stage I and II oropharyngeal carcinomasquamous cell carcinoma (OPSCC).

BACKGROUND

The traditional primary treatment modality of OPSCC at early stages is intensity modulated radiation therapy (IMRT). Trans-oral robotic surgery (TORS) has offered as an alternative, less invasive surgical option. Patients with human papilloma virus (HPV)-positive OPSCC have distinct staging with better overall survival in comparison with HPV-negative OPSCC patients.

METHODS

a comprehensive review of the English language literature was performed using PubMed, EMBASE, the Cochrane Library, and CENTRAL electronic databases.

CONCLUSIONS

Many trials started examining the role of TORS in de-escalating treatment to optimize functional consequences while maintaining oncologic outcome. The head-neck surgeon has to know the current role of TORS in HPV-positive and negative OPSCC and the ongoing trials that will influence its future implementation. The feasibility of this treatment, the outcomes ensured, and the side effects are key factors to consider for each patient. The variables reported in this narrative review are pieces of a bigger puzzle called tailored, evidence-based driven medicine. Future evidence will help in the construction of robust and adaptive algorithms in order to ensure the adequate treatment for the OPSCC at early stages.

Transpharyngeal Approaches for Management of Oropharyngeal Squamous Cell Carcinoma: Mayo Clinic Institution Experience

OBJECTIVE

Investigate oncologic and functional outcomes associated with transhyoid and lateral pharyngotomy (transpharyngeal) approaches in the treatment of oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective review.

SETTING

Single institution (tertiary care center).

METHODS

This is a retrospective case series of patients with OPSCC undergoing transpharyngeal resection from 1990 to 2017 at Mayo Clinic. Oncologic outcomes, postoperative complications, objective swallowing data, and rates of tracheostomy and percutaneous gastrostomy tube dependence were recorded.

RESULTS

Of 83 patients meeting inclusion criteria, 56 (68%) were human papillomavirus positive. Overall survival rates at 5 and 10 years following surgery were 85% and 80%, respectively. Cancer-specific survival rates at these same time points were 90% and 88%. Following treatment, 35 of 49 patients (71%) had a Functional Oral Intake Scale score ≥5, indicating total oral intake of multiple consistencies; 79 of 82 (96%) were without tracheostomy or laryngectomy; and 71 of 81 (88%) were on a full oral diet.

CONCLUSION

Transpharyngeal approaches provide adequate functional and oncologic outcomes in the majority of patients with OPSCC. These results may have important implications for patients who are not candidates for, or are unwilling to undergo, nonoperative therapy or for those without access to radiation therapy.

Post-operative outcomes of different surgical approaches to oropharyngeal squamous cell cancer: a case-matched study

OBJECTIVE

To compare the post-operative outcomes of transoral laser microsurgery, lateral pharyngotomy and transmandibular surgery in oropharyngeal cancer management.

METHODS

Records of 162 patients treated with transmandibular surgery, transoral laser microsurgery or lateral pharyngotomy were reviewed. The transoral laser microsurgery cohort was matched with the lateral pharyngotomy and transmandibular surgery cohorts for tumour stage, tumour subsite and human papilloma virus status, and the intra- and post-operative outcomes were compared.

RESULTS

Duration of surgery and hospital stay were significantly longer for transmandibular surgery. Tracheostomy and nasogastric feeding tube rates were similar, but time to decannulation and to oral feeding were longer in the transmandibular surgery group. Transmandibular surgery more frequently required flap reconstruction and had a greater complication rate. Negative margins were fewer in the lateral pharyngotomy group than in the transoral laser microsurgery and transmandibular surgery groups.

CONCLUSION

In comparison with transmandibular surgery, transoral laser microsurgery and lateral pharyngotomy were associated with fewer complications and faster functional recovery. Lateral pharyngotomy had a higher rate of positive margins than transoral laser microsurgery, with a consequently greater need for adjuvant therapy. Many patients are nonetheless unsuitable for transoral surgery. All these factors should be considered when deciding on oropharyngeal cancer surgical treatment.

[Surgical therapy of oropharyngeal cancer-state of the art]

Surgical therapy, regardless of the procedure, remains of great importance for today's treatment of oropharyngeal carcinomas, despite advances in radiation and immunotherapy. The individual treatment plan should be defined in discussion with the patient and in an interdisciplinary tumor conference, taking into account the likelihood of achieving of tumor-free resection margins and an acceptable postoperative quality of life. With regard to conventional and possibly also open surgical procedures, a good overview of the surgical site-particularly in the case of more extensive carcinomas and challenging patient anatomy-and simplified reconstructability of the defect region are decisive aspects. Endoscopically, microsurgically, or even robot-assisted minimally invasive procedures have the advantage of precise and gentle removal of tumor tissue with improved maintenance of function. Overall, selection of the appropriate surgical procedure remains an individual decision based on tumor size, the facilities at the tumor center, and the surgeon's experience. The extent of surgical intervention, also with regard to simultaneous neck dissection, depends on tumor stage. In the case of oropharyngeal carcinomas, there will be an increasing distinction between human papillomavirus (HPV)-negative and HPV-positive tumors in the future; however, the therapeutic strategy is currently identical. Upcoming clinical trials will show whether treatment de-escalation is appropriate depending on HPV infection status.

Improving exposure for transoral oropharyngeal surgery with the floor of mouth window: a cadaveric feasibility study

Background

Transoral robotic and laser surgery is rising in popularity due to the increasing incidence of Human Papilloma Virus (HPV) related oropharyngeal cancer. However, adequate exposure of the tongue base remains a major hurdle in many cases. This study introduces a novel surgical technique called the Floor of Mouth Window, which can be used to improve tongue base exposure at the time of transoral surgery.

Methods

This is a preclinical anatomic cadaver study. Seven fresh cadavers were used for this study. Exposure of the tongue base was compared between conventional mouth gags – the Feyh-Kastenbauer and McIvor – and our novel procedure, the Floor of Mouth Window. Exposure was compared subjectively using endoscopic and extracorporeal photographs, as well as objective measurements of inter-incisor distance, and oral cavity volume.

Results

The exposure achieved by the Floor of Mouth Window technique was superior to the mouth gags. Inter-incisor distance and oral cavity volume measurements were all more favorable with the Floor of Mouth Window. This technique allowed for successful transoral laser tongue base and tonsil resection without the use of gags or scopes.

Conclusion

The Floor of Mouth Window is an adjunctive procedure that simply and reliably improved exposure for transoral oropharyngeal surgery in this cadaveric feasibility study. This improved exposure may help increase the adoption of transoral surgery and reduce the number of aborted cases due to anatomic limitations.

Lateral pharyngotomy

Based on a review of the medical literature, the authors document the key technical points, variants, technical errors to avoid and main functional results of lateral pharyngotomy for resection of cancers originating from the lateral oro and/or hypopharynx.