The interplay of IMRT and transoral surgery in HPV-mediated oropharyngeal cancer: Getting the balance right

Recurrent Versus Metastatic Head and Neck Cancer: An Evolving Landscape and the Role of Immunotherapy

Squamous cell carcinoma of the head and neck (SCCHN) is among the ten most common cancers worldwide, with advanced SCCHN presenting with a 5-year survival of 34% in the case of nodal involvement and 8% in the case of metastatic disease. Disease-free survival at 2 years is 67% for stage II and 33% for stage III tumors, whereas 12-30% of patients undergo distant failures after curative treatment. Previous treatments often hinder the success of salvage surgery and/or reirradiation, while the standard of care for the majority of metastatic SCCHN remains palliative chemo- and immuno-therapy, with few patients eligible for locoregional treatments. The aim of this paper is to review the characteristics of recurrent SCCHN, based on different recurrence sites, and metastatic disease; we will also explore the possibilities not only of salvage surgery and reirradiation but also systemic therapy choices and locoregional treatment for metastatic SCCHN.

Upfront transoral robotic surgery (TORS) versus intensity-modulated radiation therapy (IMRT) in HPV-positive oropharyngeal cancer: real-world data from a tertiary comprehensive cancer center

Objective

Methods

Results

Conclusions

Surgeon practice patterns in transoral robotic surgery for HPV-related oropharyngeal cancer

OBJECTIVES

Analyze how otolaryngologists approach HPV-related oropharyngeal cancer in terms of patient selection for transoral surgery, perceptions of treatment related risks and benefits, and adjuvant treatment decisions.

MATERIALS AND METHODS

A survey on HPV-related cancer management was distributed to otolaryngologists in the US through RedCap. Differences in responses were analyzed using Pearson's chi-squared and Fisher's exact tests.

RESULTS

A total of 111 out of 143 (77.6%) otolaryngologists completed the survey. Overall, most prefer treating T1/T2 tumors using transoral robotic surgery (TORS) and T3 tumors through primary radiation therapy (RT), though there were significant differences between cohorts. Non-fellowship-trained surgeons and those in community practices favored RT for T1/T2 more than their fellowship-trained and academic counterparts, respectively. For adjuvant treatment, non-fellowship-trained surgeons favored adjuvant CRT, whereas fellowship-trained surgeons preferred only adjuvant RT, for patients with lymphovascular or perineural invasion, >1 lymph node involvement, or close deep margins. TORS was viewed as having less adverse sequelae (i.e. dysphagia, dysphonia, xerostomia). Though the two modalities had similar oncologic outcomes, TORS was perceived as providing better quality of life (QOL).

CONCLUSIONS

There are variations in HPV-related OPSCC management based on surgeon background and preferences across the US. TORS and primary RT are believed to offer similar oncologic control, but the former provides lesser adverse sequelae and better QOL. Additionally, surgeon demographics (i.e. fellowship status, practice type, and region) can affect management decisions, including patient selection for TORS and adjuvant therapy decisions. Further study is required to better understand and standardize appropriate HPV-positive OPSCC management.

Decreasing treatment burden in HPV-related OPSCC: A systematic review of clinical trials

INTRODUCTION

Favorable outcomes are observed after treatment with standard chemoradiotherapy (CRT) for Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) patients. The consistent growing interest on treatment-related toxicity burden, potentially jeopardizing survivors' quality of life, led clinicians to investigate possible de-escalation strategies.

MATERIALS AND METHODS

A comprehensive systematic literature search of clinical trials was performed through the EMBASE database to provide an overview of the de-escalation strategies spectrum. Additionally, hand searching and clinicaltrials.gov were also used.

RESULTS

Herein, we report and discuss different approaches to de-escalation of therapy, with respect to both local and systemic strategies.

CONCLUSIONS

Several promising de-escalation experiences have been published. However, while further evidence is awaited, no changes in the management nor deviation from the standard of care should be made outside of clinical trials.

Potential therapeutic implications of the new tumor, node, metastasis staging system for human papillomavirus-mediated oropharyngeal cancer

PURPOSE OF REVIEW

The 8th edition tumor, node, metastasis (TNM) classification (TNM-8) introduced a new classification for human papillomavirus (HPV)-mediated oropharyngeal carcinoma (HPV+ OPC). This review summarizes its potential therapeutic implications focusing on literature published since 2018.

RECENT FINDINGS

The following are active research areas involved in clinical care and therapy relevant to TNM-8: tumor HPV testing and its clinical implications; stage I disease: treatment selection and lessons learned from recent deintensification trials; emerging strategies addressing stage II and III disease.

SUMMARY

The TNM-8 classification depicts prognosis of HPV+ OPC much more reliably compared with TNM-7. Among the advantages in outcome comparison and stratification for clinical trial entry and conduct, it also enables more satisfactory individual patient consultation to adequately estimate prognosis, and facilitates clinical and translational research. However, clinicians must remain mindful that the TNM classification is not a guideline for treatment but, instead, provides a framework for clinical research and treatment decision-making. The TNM-8 has potential to improve risk-tailored treatment algorithms for HPV+ OPC including selection of treatment modality (primary trans-oral surgery vs. radiotherapy, addition of chemotherapy) and adjusting the intensity of approaches. To realize these goals fully, it is apparent that the TNM-8 needs to evolve further.

[The role of surgery and salvage surgery in the era of HPV-associated oropharyngeal carcinomas]

The incidence of human papillomavirus (HPV)-positive oropharyngeal carcinomas is increasing worldwide. Due to a markedly different response to treatment compared to HPV-negative oropharyngeal carcinomas, determining the ideal therapeutic approach can be challenging. Particularly in never-smokers, HPV-positive oropharyngeal carcinomas respond well to primary radiation therapy; at the same time recent studies indicate comparable survival after primary surgery. For stage I tumors according to TNM‑8, retrospective analyses show very good oncologic outcomes after surgery alone, and no added benefit of adjuvant radio- or chemotherapy. Results of prospective treatment deintensification trials are expected in the coming years. Minimally invasive transoral surgical approaches for selected oropharyngeal cancers can improve preservation of postoperative function and quality of life. For both HPV-positive and HPV-negative oropharyngeal carcinomas, salvage surgery is the treatment of choice for resectable recurrent locoregional disease and resectable distant metastases.

Genomics and precision surgery for head and neck squamous cell carcinoma

The identification of the biological determinants that shape the response of tumors to medical therapies offers perspectives for better patient stratification and therapeutic targeting. Here, we discuss how genomics could help to improve the surgical treatment of head and neck squamous cell carcinoma (HNSCC). We examine the potential use of genomic analyses for: i) refining and standardizing the indications for surgery, ii) the choice of surgical procedure, and iii) the follow-up of patients with resected tumors. We highlight the studies that used genomics to explore the contribution of tumor biology to the outcome of surgery. We discuss the important developments that are challenging current surgical practice in HNSCC, such as neoadjuvant immunotherapy and the analysis of circulating DNA. Genomic analyses provide practical tools that could help improve the pathological diagnosis and staging of HNSCC, and increase the appreciation of the importance of tumor biology in the outcome of surgery. Identification of biomarkers will likely contribute to a move toward precision surgery of HNSCC, i.e. the personalization of surgical practice based on tumor biology.