Role of surgery in limited (T1-2, N0-1) cancers of the oropharynx

[Surgical Treatment of Hypopharyngeal Carcinoma, Neck Dissection and Adjuvant Postoperative Therapy of Oropharyngeal and Hypopharyngeal Cancer: Recommendations of the current S3 Guideline - Part II]

Part II of the S3 guideline report deals with the surgical treatment of hypopharyngeal carcinoma, neck dissection for oropharyngeal and hypopharyngeal carcinomas and adjuvant therapy options. Primary surgical therapy ± adjuvant radio- or radiochemotherapy and primary radio- or radiochemotherapy are established as primary therapies for local-regional hypopharyngeal carcinomas. Direct randomized comparisons of both basic therapeutic procedures were never conducted. Available registry data show a worse prognosis of hypopharyngeal carcinoma compared to oropharyngeal carcinomas in all locoregional tumor stages, regardless of the treatment method. For T1N0-T2N0 squamous cell carcinoma of the hypopharynx, there are no relevant differences in overall survival and locoregional relapse rate between primary surgical and primary non-surgical treatment. Primary surgical therapy ± adjuvant radiotherapy or radiochemotherapy and primary radiotherapy or radiochemotherapy are established as primary therapies for advanced but locoregionally limited hypopharyngeal carcinomas. Neck dissection is an integral part of the primary surgical treatment of oropharyngeal and hypopharyngeal cancer. There are only a few randomized studies on non-surgical organ preservation for advanced hypopharyngeal cancer as an alternative to pharyngolaryngectomy, but these have led to the recommendation of alternative concepts in the new guideline. The indication and implementation of postoperative adjuvant radiotherapy and radiochemotherapy for hypopharyngeal carcinoma do not differ from those for HPV/p16-negative and -positive oropharyngeal carcinoma.

[Nodal metastasis and value of neck dissection in T1/2 oropharyngeal and hypopharyngeal carcinomas]

BACKGROUND

Due to heterogeneous data, the indication for elective neck dissection (END) in patients with squamous cell carcinoma of the hypopharynx and oropharynx (HPSCC and OPSCC) in stages T1/2N0 is somewhat unclear. Therefore, in this multicenter study, we performed detailed analysis of the metastatic behavior of HPSCC and OPSCC.

MATERIAL AND METHODS

The nodal metastatic patterns of 262 HPSCC and OPSCC patients who had undergone surgery was retrospectively investigated. In addition, recurrence-free and overall survival were recorded. Furthermore, a systematic literature review on the topic was completed.

RESULTS

In patients with HPSCC, a discrepancy between clinical and pathologic N status was recorded in 62.1% of patients vs. 52.4% for p16- OPSCC, and 43.6% for p16+ OPSCC. The occult metastasis rate in cT1/2cN0 primary tumors was 38.9% for HPSCC vs. 17.8% (p16- OPSCC) and 11.1% (p16+ OPSCC). Contralateral metastases occurred in 22.2% of cases for HPSCC at stages cT1/2cN0, compared to only 9.1% for p16- OPSCC, and 0% for p16+ OPSCC patients.Patients with p16+ OPSCC had better recurrence-free and overall survival than p16- OPSCC and HPSCC patients. A direct association between patient survival and the extent of neck surgical therapy could not be demonstrated in our patients.

CONCLUSION

Patients with HPSCC are at risk for bilateral neck metastases from stage cT1/2cN0, justifying bilateral END. Patients with T1/2 OPSCC present with occult metastases ipsilaterally in >20% of cases; however, the risk for contralateral occult metastasis is <10%. Hence, in strictly lateralized cT1/2CN0 tumors, omission of contralateral END may be considered.

Response to Neoadjuvant Targeted Therapy in Operable Head and Neck Cancer Confers Survival Benefit

PURPOSE

Neoadjuvant targeted therapy provides a brief, preoperative window of opportunity that can be exploited to individualize cancer care based on treatment response. We investigated whether response to neoadjuvant therapy during the preoperative window confers survival benefit in patients with operable head and neck squamous cell carcinoma (HNSCC).

PATIENTS AND METHODS

A pooled analysis of treatment-naïve patients with operable HNSCC enrolled in one of three clinical trials from 2009 to 2020 (NCT00779389, NCT01218048, NCT02473731). Neoadjuvant regimens consisted of EGFR inhibitors (n = 83) or anti-ErbB3 antibody therapy (n = 9) within 28 days of surgery. Clinical to pathologic stage migration was compared with disease-free survival (DFS) and overall survival (OS) while adjusting for confounding factors using multivariable Cox regression. Circulating tumor markers validated in other solid tumor models were analyzed.

RESULTS

92 of 118 patients were analyzed; all patients underwent surgery following neoadjuvant therapy. Clinical to pathologic downstaging was more frequent in patients undergoing neoadjuvant targeted therapy compared with control cohort (P = 0.048). Patients with pathologic downstage migration had the highest OS [89.5%; 95% confidence interval (CI), 75.7-100] compared with those with no stage change (58%; 95% CI, 46.2-69.8) or upstage (40%; 95% CI, 9.6-70.4; P = 0.003). Downstage migration remained a positive prognostic factor for OS (HR, 0.22; 95% CI, 0.05-0.90) while adjusting for measured confounders. Downstage migration correlated with decreased circulating tumor markers, SOX17 and TAC1 (P = 0.0078).

CONCLUSIONS

Brief neoadjuvant therapy achieved pathologic downstaging in a subset of patients and was associated with significantly better DFS and OS as well as decreased circulating methylated SOX17 and TAC1.

Therapeutic strategies: Surgery for human papillomavirus-associated oropharyngeal carcinoma

Treatment of oropharyngeal cancer (OPC) has undergone considerable evolution since the discovery of human papillomavirus (HPV)-associated OPC. It is widely understood that HPV OPC affects a younger population and standard treatment offers improved oncologic outcomes compared with non-HPV OPC but can cause significant toxicities and long-term side effects. Surgery for treatment de-escalation is an active area of research. The purpose of this review is to explore surgery as it relates to the treatment of HPV OPC with a focus on the evolution of treatment, rationale for surgery, surgical techniques, outcomes, and the role of surgery in de-escalation of treatment.

Patterns of cervical lymph node metastasis in supraglottic laryngeal cancer and therapeutic implications of surgical staging of the neck

Purpose

Accurate therapeutic management of the neck is a challenge in patients with supraglottic laryngeal cancer. Nodal metastasis is common at all disease stages, and treatment planning relies on clinical staging of the neck, for both surgical and non-surgical treatment. Here, we compared clinical and surgical staging results in supraglottic carcinoma patients treated with primary surgery to assess the accuracy of pre-therapeutic clinical staging and guide future treatment decisions.

Methods

Retrospective analysis of clinical, pathological, and oncologic outcome data of 70 patients treated with primary surgery and bilateral neck dissection for supraglottic laryngeal cancer. Patients where clinical and pathological neck staging results differed, were identified and analyzed in detail.

Results

On pathologic assessment, patients with early stage (pT1/2) primaries showed cervical lymph node metastases in 55% (n = 17/31) of cases, compared to 67% (n = 26/39) of patients with pT3/4 tumors. In 24% (n = 17/70) of all patients, cN status differed from pN status, resulting in an upstaging in 16% of cases (n = 11/70) and a downstaging in 9% (n = 6/70) of cases. 14% of patients with cN0 status had occult metastases (n = 5/30). As assessed by a retrospective tumor board, in case of a non-surgical treatment approach, the inaccurate clinical staging of the neck would have led to an over- or undertreatment of the neck in 20% (n = 14/70) of all patients.

Conclusion

Our data re-emphasize the high cervical metastasis rates of supraglottic laryngeal cancer across all stages. Inaccurate clinical staging of the neck is common and should be taken into consideration when planning treatment.

[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.

Treatment preferences in human papillomavirus-associated oropharyngeal cancer

The population of survivors with human papillomavirus-associated oropharyngeal squamous cell carcinoma (HPV-OPSCC) is rising. The improved prognosis of this etiologic subset is reflected in new staging guidelines as well as ongoing deintensification trials aiming to preserve excellent survival while decreasing treatment-related toxicities. However, as staging criteria and treatment standards evolve in the era of transoral surgery and deintensification, little is known regarding the needs and treatment preferences of patients with HPV-OPSCC. Herein, the current knowledge regarding treatment preferences and priorities, quality of life and concerns among patients with HPV-OPSCC is reviewed.

Outcomes of transoral laser microsurgery for oropharyngeal squamous cell carcinoma in Ireland and review of the literature on transoral approaches

BACKGROUND

The optimal treatment for oropharyngeal squamous cell carcinoma (OPSCC) is controversial. There is increasing evidence that, in selected cases, minimally invasive transoral surgery can offer improved functional outcomes, with equivalent oncologic outcomes, compared to chemoradiotherapy.

AIMS

We report the outcomes of transoral laser microsurgery (TLM) for treatment of OPSCC at our institution.

METHODS

Patients with OPSCC undergoing TLM at the South Infirmary Victoria University Hospital, Cork, between 2010 and 2016, were identified from an institutional database. Human papillomavirus (HPV) status was determined by p16 immunohistochemistry. Survival outcomes were analysed using the Kaplan-Meier method. Complications following surgery and gastrostomy tube dependence were evaluated.

RESULTS

The study cohort consisted of 26 patients, with mean age of 56 years (range 29-71). Primary tumours were located in the tonsil (18), base of tongue (4) and other subsites (4). Seventeen cases were p16-positive. Complications included haemorrhage necessitating return to theatre (1) and aspiration pneumonia (1). Four patients underwent tracheostomy, all of whom were successfully decannulated. One patient underwent gastrostomy tube insertion during postoperative radiotherapy. No patient was gastrostomy dependent at latest follow-up. Twenty-two patients received adjuvant treatment, with radiation alone (21) or chemoradiotherapy (2). Mean follow-up was 27 months. Five-year locoregional control was 92% and disease-specific survival was 81%.

CONCLUSIONS

In selected patients with OPSCC, TLM offers excellent functional and survival outcomes, and as such offers an alternative approach to chemoradiotherapy as primary treatment. We compare TLM to other transoral approaches and discuss its potential use in the Irish healthcare system.

Treatment outcome of advance staged oral cavity cancer: concurrent chemoradiotherapy compared with primary surgery

Concurrent chemoradiotherapy (CCRT) has been reported as effective and has become an acceptable treatment in advanced oral cancer. However, to date there is insufficient data to conclude that CCRT provides a good survival outcome. The purpose of this study was to compare survival rates and complications in patients with resectable advanced oral cavity squamous cell carcinoma treated with either CCRT or surgery with adjuvant radiotherapy (RT)/chemoradiotherapy (CRT). Stage III or IVa oral cavity carcinoma patients treated with curative intent by either CCRT or surgery with adjuvant RT were identified over a 7-year period (2009-2015). Survival rates and treatment complications were analyzed and compared between the two groups. 61 patients underwent CCRT and 128 patients underwent surgical excision and received postoperative RT. There was no statistically significant difference in survival outcome between the two treatment groups. 5-year overall survival rates (OS) were 33 versus 24% (P = 0.191) and the disease-specific survival rates (DSS) were 27 versus 25% (P = 0.857) when comparing the CCRT group and surgery with adjuvant RT/CRT group, respectively. Long-term complications were comparable between the two groups. CCRT has comparable survival outcome and complications for the treatment of advanced oral cavity squamous cell carcinoma, compared to surgery with adjuvant RT/CRT.

Considerations in surgical versus non-surgical management of HPV positive oropharyngeal cancer

Given the marked difference in clinical presentation and treatment response based on human papilloma virus (HPV) status, HPV-associated oropharyngeal squamous cell carcinoma is now viewed as a distinct biologic and clinical entity. HPV-associated oropharyngeal squamous cell carcinoma has increased by nearly 7.5 % per year, from approximately 16 % in the early 1980′s to nearly 70 % today, and is believed will continue to increase dramatically in the coming years. Currently, a myriad of treatment options exist for these patients as many active clinical trials are underway which aim to identify the most appropriate interventions for this unique group of patients. This review aims to provide considerations between surgical and non-surgical management for HPV-associated oropharyngeal squamous cell carcinoma.

Infrahyoid flap in oropharyngeal reconstruction following carcinoma resection: A study of 6 patients and literature review

The present study aimed to describe the techniques used and the results obtained with the infrahyoid flap for the reconstruction of medium-sized oropharyngeal defects following resection for advanced squamous cell cancer. During a period of 1 year, six patients with oropharyngeal defects were reconstructed using the infrahyoid flap. The tumor characteristics, location and size of the defect, resective and reconstructive techniques employed and the complications and outcomes of the speech and swallowing functions, as identified in the follow-up visits every 3 months, were evaluated. All flaps were performed simultaneously in association with tumoral excision and ipsilateral supraomohyoid neck dissection. The mean size of the skin paddle was 7.0×3.5 cm. The donor site was primarily sutured. The postoperative course was uneventful and all flaps were viable. One case of marginal skin paddle loss occurred without affecting the survival of the flap. Five patients received postoperative radiotherapy and one patient received concurrent postoperative chemotherapy. During the follow-up period (mean, 63 months), all patients showed excellent oral swallowing. Speech was excellent in five patients and in one patient speech was classified as good. The aesthetic results of the cervical donor site were good. Based on the present case report and the literature review, the infrahyoid flap is a simple and safe procedure for the reconstruction of the oropharynx, with a high success rate, minimal donor site morbidity and good aesthetic and functional results. The infrahyoid flap is a valid surgical option that may be considered in selected oncological patients undergoing reconstruction of medium-size oropharyngeal defects.

Oncologic outcomes of surgically treated early-stage oropharyngeal squamous cell carcinoma

BACKGROUND

The purpose of this study was to characterize oncologic outcomes in early (T1-T2, N0) and intermediate (T1-T2, N1) oropharyngeal squamous cell carcinoma (SCC) after surgery.

METHODS

Patients with oropharyngeal SCC treated with surgery were identified from 2 academic institutions.

RESULTS

Of 188 patients, 143 met the inclusion criteria. Eighty-six (60%) had T1 to T2 N0 and 57 (40%) had T1 to T2 N1 disease. Sixty-five patients (45%) underwent a robotic-assisted resection, whereas the remaining had transoral (n = 60; 42%), mandible-splitting (n = 11; 8%), or transhyoid approaches (n = 7; 5%). Human papillomavirus (HPV) status was known for 97 patients (68%), and 54 (55%) were HPV positive. Three-year recurrence-free survival (RFS) was 82% (95% confidence interval [CI] = 0.75-0.89). Since 2008, HPV infection was protective of recurrence (log-rank p = .0334). A single node did not increase the risk of recurrence (p = .467) or chance of a second primary (p = .175).

CONCLUSION

Complete surgical resection is effective therapy for early and intermediate oropharyngeal SCC. HPV-negative patients were at increased risk for locoregional recurrence or second primary disease. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1471, 2016.

A pilot study to compare the detection of HPV-16 biomarkers in salivary oral rinses with tumour p16(INK4a) expression in head and neck squamous cell carcinoma patients

Background

Human papilloma virus-16 (HPV-16) infection is a major risk factor for a subset of head and neck squamous cell carcinoma (HNSCC), in particular oropharyngeal squamous cell carcinoma (OPSCC). Current techniques for assessing the HPV-16 status in HNSCC include the detection of HPV-16 DNA and p16^INK4a expression in tumor tissues. When tumors originate from hidden anatomical sites, this method can be challenging. A non-invasive and cost-effective alternative to biopsy is therefore desirable for HPV-16 detection especially within a community setting to screen at-risk individuals.

Methods

The present study compared detection of HPV-16 DNA and RNA in salivary oral rinses with tumor p16^INK4a status, in 82 HNSCC patients using end-point and quantitative polymerase chain reaction (PCR).

Results

Of 42 patients with p16^INK4a-positive tumours, 39 (sensitivity = 92.9 %, PPV = 100 % and NPV = 93 %) had oral rinse samples with detectable HPV-16 DNA, using end-point and quantitative PCR. No HPV-16 DNA was detected in oral rinse samples from 40 patients with p16^INK4a negative tumours, yielding a test specificity of 100 %. For patients with p16^INK4a positive tumours, HPV-16 mRNA was detected using end-point reverse transcription PCR (RT-PCR) in 24/40 (sensitivity = 60 %, PPV = 100 % and NPV = 71 %), and using quantitative RT-PCR in 22/40 (sensitivity = 55 %, PPV = 100 % and NPV = 69 %). No HPV-16 mRNA was detected in oral rinse samples from the p16^INK4a-negative patients, yielding a specificity of 100 %.

Conclusions

We demonstrate that the detection of HPV-16 DNA in salivary oral rinse is indicative of HPV status in HNSCC patients and can potentially be used as a diagnostic tool in addition to the current methods.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2217-1) contains supplementary material, which is available to authorized users.

Tumor volume as a predictor of survival in human papillomavirus-positive oropharyngeal cancer

BACKGROUND

Increasing evidence exists that tumor volume may be a superior prognostic model than traditional TNM staging. It has been observed that oropharyngeal squamous cell carcinoma (oropharyngeal SCC) in the setting of human papillomavirus (HPV) positivity have a greater propensity for cystic nodal metastases, and, thus, presumably larger volume with relatively smaller primary tumors. The influence of HPV status on the predictive value of tumor volume is unknown.

METHODS

Fifty-three patients with HPV-positive oropharyngeal SCC were treated with definitive chemotherapy and intensity-modulated radiotherapy (IMRT).

RESULTS

The estimated 2-year overall survival (OS) and disease-free survival (DFS) was 92.2% and 83.6%, respectively. Nodal classification did not predict OS (p = .096) or DFS (p = .170). Similarly, T classification did not predict OS (p = .057) or DFS (p = .309). Lower nodal volume was associated with greater DFS (p = .001).

CONCLUSION

Nodal tumor volume was found to be predictive of DFS. DFS was best predicted by nodal gross tumor volume (GTV) at 24 months. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1613-E1617, 2016.

Transoral Endoscopic Head and Neck Surgery: The Contemporary Treatment of Head and Neck Cancer

Traditional open surgical approaches are indicated for treatment of select tumor subsites of head and neck cancer, but can also result in major cosmetic and functional morbidity. Transoral surgical approaches have been used for head and neck cancer since the 1960s, with their application continuing to evolve with the changing landscape of this disease and recent innovations in surgical instrumentation. The potential to further reduce treatment morbidity with transoral surgery, while optimizing oncologic outcomes, continues to be investigated. This review examines current literature evaluating oncologic and quality-of-life outcomes achieved through transoral head and neck surgery.

Cancer of the oropharynx

The oropharynx has a crucial role in swallowing because of the surrounding constrictor musculature, need for mobility and pliability, and proximity of the base of tongue to the larynx. Human papilloma virus (HPV) infection as a cause of oropharyngeal squamous cell carcinoma has increased dramatically in proportion and overall numbers of oropharyngeal squamous cell carcinoma cases. Better clinical response to therapy and younger age of the HPV+ oropharyngeal squamous cell carcinoma patients have caused functional and quality-of-life considerations to become more important endpoints in evaluating efficacy of therapeutic options; "deintensification" to ameliorate toxicity is under investigation for this population.

The role of surgery for HPV-associated head and neck cancer

The incidence of human papillomavirus (HPV)-associated oropharyngeal cancer continues to increase in contrast to other head and neck cancer sites. There is a growing role for upfront surgery to treat these cancers in the era of organ preservation treatment strategies. This is becoming especially important in younger, healthier patients with HPV-associated squamous cell carcinoma. Surgery for oropharyngeal cancer has evolved from large, open transcervical and transmandibular approaches to minimally-invasive transoral endoscopic techniques. Advances in transoral endoscopic surgery (TES) have led to renewed interest in upfront surgical treatment for oropharyngeal carcinoma. Transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) are two techniques that allow for complete oncologic resection through the mouth in select patients, with minimal cosmetic deformity and optimal speech and swallow function after completion of therapy. In this article we will review transoral approaches to oropharyngeal carcinoma: its oncologic and functional outcomes, and its role in the multi-disciplinary treatment of oropharyngeal cancer.

Concurrent chemoradiotherapy compared with surgery and adjuvant radiotherapy for oral cavity squamous cell carcinoma

BACKGROUND

The purpose of this study was to compare survival and functional outcomes in patients with advanced oral cavity squamous cell carcinoma (SCC) treated with either surgery + adjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CRT).

METHODS

Patients treated with curative intent by either surgery + RT or concurrent CRT were identified over a 6-year period (2001-2007). Disease and functional outcomes were analyzed on an intention-to-treat basis.

RESULTS

Fifty-four patients underwent surgical excision and received postoperative RT. Fifty patients underwent concurrent CRT. Overall survival (OS) and disease-specific survival (DSS) was significantly higher in the surgically treated group (p < .001). Long-term enteral feeding tube support was more commonly required in those treated with CRT, whereas osteoradionecrosis rates were comparable between the 2 groups.

CONCLUSION

Treatment by surgery + adjuvant RT for advanced oral cavity SCC resulted in better disease control than treatment with CRT. This supports traditional surgical treatment algorithms for oral cavity cancer.

Robotic surgery for oropharyngeal cancer

Oropharyngeal cancer represents a growing proportion of head and neck malignancies. This has been associated with the increase in infection of the oropharynx by oncogenic strains of human papillomavirus (HPV). Transoral robotic surgery (TORS) has opened the door for minimally invasive surgery for HPV-related and non-HPV-related oropharyngeal cancer. Compared to traditional open surgical approaches, TORS has been shown to improve functional outcomes in speech and swallowing, while maintaining good oncologic outcomes.

Early stage oropharyngeal carcinomas: comparing quality of life for different treatment modalities

OBJECTIVE

To compare long-term quality of life outcomes after treating early stage oropharyngeal carcinoma either with surgery, surgery combined with radiotherapy, or surgery combined with chemoradiotherapy.

METHODS

Questionnaire based method: 111 eligible patients agreed to fill out a quality of life questionnaire.

RESULTS

Of the 32 scales contained in the EORTC's combined QLQ-C30 and HN35, 11 scales show significantly better results for the surgery-only treatment group when compared to either surgery combined with radiotherapy or surgery combined with any type of adjuvant therapy. These eleven scales are role function (P = 0.019/0.008), social function (P = 0.01/0.034), nausea (P = 0.017/0.025), pain (P = 0.014/0.023), financial problems (P = 0.030/0.012), speech (P = 0.02/0.015), social eating (P = 0.003/<0.001), mouth opening (P = 0.033/0.016), sticky saliva (P = 0.001/<0.001), swallowing (P < 0.001/<0.001), and dry mouth (P < 0.001/0.001).

CONCLUSION

Treatment of early stage oropharyngeal carcinoma with surgery alone has definite advantages over treatments including any form of adjuvant therapy when considering quality of life. Advantages manifest themselves especially in functional aspects of the head and neck realm; however general health aspects as well as psychosocial aspects show improvements as well. This study does not show any indication of QOL-related drawbacks of surgery-only treatment approaches.

Soft palate preservation after tumor resection with transoral laser microsurgery

Background: Management and preservation of the soft palate is dependent on clinical stage and tumor histology. However, available literature is scarce regarding the palate preservation with the use of laser CO2. Objectives: We report the results obtained after management with laser surgery and soft palate preservation in three patients with salivary gland neoplasms. Method: Three patients with minor salivary gland tumors were treated by means of transoral laser microsurgery. All tumors were assessed using magnetic resonance imaging. All tumors were >3 cm. Soft palate function was preserved and reconstruction was performed with primary closure. Patients began oral feeding the same day and were discharged after 24 h. Conclusions: Transoral laser microsurgery is recommended for treatment of soft palate tumors. This treatment can be considered a better option when compared with other modalities such as radio- or chemoradiotherapy which require a longer time of treatment, are more expensive and tend to produce significant toxicity.

Key words:Laser CO2, neoplasms, salivary gland.

Role of surgery in the management of head and neck cancer: a contemporary view of the data in the era of organ preservation

OBJECTIVE

Review of the literature on the role of surgery in the management of head and neck cancer in the era of organ preservation.

METHOD

Literature search based on the essential practice guidelines set out by the US National Comprehensive Cancer Network.

RESULTS

Despite the increasing popularity of non-surgical treatment options, the surgeon remains a key figure in the multidisciplinary head and neck cancer team, along with the radiation oncologist, the medical oncologist and the speech and swallowing therapist. Even when organ preservation is successful, early and late toxicity may cause serious complications, including laryngeal dysfunction with a 'frozen larynx'. When organ preservation fails, salvage surgery is often associated with increased complications and reduced survival.

CONCLUSION

There is a definite need to apply more rigorous standards to the use of organ preservation strategies, and to re-evaluate the role of surgery in head and neck cancer treatment.

Transoral treatment strategies for head and neck tumors

The introduction of transoral endoscopic surgery has initiated a fundamental change in the treatment of head and neck cancer. The endoscopic approach minimizes the intraoperative trauma. Due to the lower burden for the patient and the savings potential these methods have gained wide acceptance. These transoral accesses routes allow experienced surgeons to reduce the morbidity of surgical resection with no deterioration of oncologic results. This suggests a further extension of the indication spectrum and a high growth potential for these techniques and equipment in the coming years. For selected patients with selected tumors the minimally invasive transoral surgery offers improved oncological and functional results. In the present paper, different surgical access routes are presented and their indications discussed.

Transoral resection of pharyngeal cancer: summary of a National Cancer Institute Head and Neck Cancer Steering Committee Clinical Trials Planning Meeting, November 6-7, 2011, Arlington, Virginia

Recent advances now permit resection of many pharyngeal tumors through the open mouth, an approach that can greatly reduce the morbidity of surgical exposure. These transoral techniques are being rapidly adopted by the surgical community and hold considerable promise. On November 6-7, 2011, the National Cancer Institute sponsored a Clinical Trials Planning Meeting to address how to further investigate the use of transoral surgery, both in the good prognosis human papillomavirus (HPV)-initiated oropharyngeal cancers, and in those with HPV-unrelated disease. The proceedings of this meeting are summarized.

Outcome of patients with early T1 and T2 squamous cell carcinoma of the base of tongue managed by conventional surgery with adjuvant postoperative radiation

BACKGROUND

Existing treatment regimens for squamous cell carcinoma (SCC) of the base of tongue (BOT) favor chemoradiation. However, there is a shifting paradigm toward minimally invasive surgery with adjuvant radiotherapy for select tumors. The aim was to report our experience in conventional surgical management with particular focus on T1/T2 tumors, which may be candidates for minimally invasive techniques.

METHODS

Between 1985 and 2005, 128 patients were treated with primary surgery. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) rates were calculated using Kaplan-Meier method, and predictive factors analyzed by univariate and multivariate analyses.

RESULTS

Five-year OS, DSS, and RFS rates were 60%, 70%, and 61%, respectively. Multivariate analysis showed pathologic T classification and extracapsular extension (ECE) were significant predictors for DSS, whereas T classification remained significant for local recurrence. DSS for T1/T2 tumors ranged from 77% (node-positive) to 84% (node-negative).

CONCLUSION

T classification and ECE are independent predictors of outcome for BOT SCC. Patients with cT1/T2 tumors had excellent outcome and may be suitable for transoral robotic or endoscopic surgical procedures.

The role of transoral robotic surgery in the management of oropharyngeal cancer: a review of the literature

Background. Transoral robotic surgery (TORS) is an emerging treatment option for the treatment of head and neck malignancies, particularly for oropharyngeal squamous cell carcinoma (OPSCC). Preliminary studies have demonstrated excellent oncologic and functional outcomes that have led to a resurgence of interest in the primary surgical management of OPSCC. The aim of the present study was to review the evidence base supporting the use of TORS in OPSCC. Methods. Studies evaluating the application of TORS in the treatment of head and neck squamous cell carcinoma (HNSCC), and more specifically OPSCC, were identified for review. Further searches were made of reference lists for complete evaluation of minimally invasive surgery (MIS) in treating OPSCC. Results. Seventeen results relating to the application of TORS in treatment of OPSCC were identified. Further results relating to the role of transoral laser microsurgery (TLM) in OPSCC were included for review. Feasibility, oncologic, and functional data is summarized and discussed. Discussion. Management strategies for patients with OPSCC continue to evolve. Minimally invasive surgical techniques including TORS and TLM offer impressive functional and oncologic outcomes particularly for patients with early T-classification and low-volume regional metastatic disease. Potential exists for treatment deintensification, particularly in patients who are HPV positive.

Robotic-assisted oropharyngeal reconstruction

The development of robotic surgery has brought new levels of precision and control to minimally invasive surgical techniques. Its effectiveness, well established in urologic and gynecologic surgery applications, has also been demonstrated in cardiac, endocrine and general surgery. Recently, trans-oral robotic approaches to oropharyngeal tumor resection have been reported and, by eliminating the need for morbid lip and mandible splitting approaches, trans-oral robotic surgery (TORS) has allowed a re-assessment of surgical options for early stage tumors which have until recently been treated primarily with chemoradiation. The application of the TORS approach to malignant and non-malignant conditions affecting the oropharynx has created the need to develop robotic-assisted methods of managing the resultant tissue defects and to assess and compare the effectiveness of these procedures. This report details our early experience with the use of robotic surgery for management of soft tissue defects of the oropharynx in 12 patients.

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.

Who are the low-risk patients that could benefit from watch-and-wait regarding the neck?

CONTEXT AND OBJECTIVE

The management of clinically negative neck is controversial, with an ongoing debate on the indication criteria and prognostic impact of different types of therapy. The aim here was to compare the results from neck dissection and watch-and-wait, among oral cancer patients who, clinically, did not show any evidence of neck metastasis.

DESIGN AND SETTING

Retrospective analysis in a tertiary cancer center hospital.

METHODS

Patients with epidermoid oral carcinoma were assessed. The inclusion criteria were: primary tumor restricted to the oral/oropharyngeal cavity, no previous treatment, surgical treatment as the first option, clinical/radiological stage N0 and no distant metastasis.

RESULTS

Two hundred and sixty-two patients were analyzed. The length of follow-up ranged from four to 369.6 months and, at the end, 118 patients were alive, 53 had died due to cancer, 84 had died from other causes and 7 had died after the operation. Among the patients who underwent neck dissection, lymphatic vascular embolization (P = 0.009) and tumor thickness (P = 0.002) were significant for regional recurrence, while for the watch-and-wait group, only tumor thickness was significant (P = 0.018). Through recursive partitioning, the patients without adverse prognostic factors and tumor thickness < 2 mm presented compatible results in the two groups.

CONCLUSION

Elective neck dissection seems to be the best treatment option. Patients who are eligible for watch-and-wait constitute a small group that, ideally, is categorized according to the postoperative pathological findings.

Therapeutic options in patients with early T stage and advanced N stage of tonsillar squamous cell carcinomas

OBJECTIVE: To compare the therapeutic role of surgery followed by radiotherapy (OPRT) and concurrent chemoradiotherapy (CCRT) in patients with early T (T1/T2) and advanced N (N2/N3) stage tonsillar squamous cell carcinoma.

STUDY DESIGN: Historical cohort study.

SETTING: A tertiary hospital.

SUBJECTS AND METHODS: The medical records of 42 patients who met the eligible criteria (24 patients were treated by OPRT, 18 patients by CCRT) were reviewed.

RESULTS: Mean overall survival (OS) and disease-free survival (DFS) were 49.0 months and 43.0 months in OPRT group, respectively, and 39.6 months and 35.0 months in CCRT group, respectively ( P = 0.18 for OS, P = 0.29 fr DFS between the two groups). There was also no significant difference in survival estimates between OPRT and CCRT group in terms of two-year OS ( P = 0.18) and two-year DFS ( P = 0.45). In the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, the scores for global health status and symptom scales did not differ between the two groups. However, the OPRT group reported better functional scales and significantly higher scores for cognitive ( P = 0.008) and social function ( P = 0.03). Among single items, a significantly lower score for insomnia ( P = 0.007) was noted in the OPRT group. In EORTC QLQ-H&N35 modules, there were no significantly different scales between the two groups except scores for nutritional supplements, in which the OPRT group presented lower symptom scores ( P = 0.02).

CONCLUSION: OPRT could be still a viable option for managing selected cases of advanced oropharyngeal cancer because one can expect comparable therapeutic outcome as well as quality of life.

Primary surgery for oropharyngeal cancer

OBJECTIVE

The development of new techniques for transoral resection has led to a renewed interest in primary surgical treatment of oropharyngeal squamous cell cancer (SCCA). We reviewed our experience with primary surgery for oropharyngeal SCCA to identify factors associated with survival.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Patients who underwent primary surgical treatment of oropharyngeal SCCA from 1985 to 2002 were analyzed. Patients who failed nonoperative treatment or had distant metastases at presentation were excluded.

RESULTS

A total of 105 patients met study criteria. The majority of patients (91%) had advanced stage disease (III/IV). All patients received postoperative radiation; chemotherapy was used in eight patients. Five-year disease-free survival was 83 percent for stage I, 67 percent for stage II, 56 percent for stage III, and 43 percent for stage IV disease. Crude local control rates were 94 percent for T1 disease, 90 percent for T2 disease, 81 percent for T3 disease, and 80 percent for T4 disease; crude regional control rates were 100 percent for N0 disease, 90 percent for N1 disease, 84 percent for N2 disease, and 82 percent for N3 disease. Cox proportional hazards models revealed that nodal stage (hazard ratio [HR] 2.3, P = 0.02) and black race (HR 2.6, P = 0.004) were the only significant predictors of disease-free survival. CONCLUSION: Primary surgical treatment of oropharyngeal SCCA is effective in achieving excellent locoregional control and permits deintensification of adjuvant therapy, even in patients with advanced stage disease. Nodal status and race are the primary determinants of disease-free survival. These data provide useful information for counseling and treatment planning.