Transoral laser microsurgery (TLM) ± adjuvant therapy for advanced stage oropharyngeal cancer (original) (raw)
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Surgical Treatment for Advanced Oropharyngeal Cancer: A Narrative Review
Medicina
Background and Objectives: to describe current scientific knowledge regarding the treatment options in advanced oropharyngeal cancer. The standard care for advanced oropharyngeal cancer (OPSCC) has been chemoradiotherapy, although surgical approaches followed by adjuvant treatment have been proposed. The best therapy for each patient should be decided by an interdisciplinary tumour-board. Different strategies should be considered for the specific patient’s treatment: surgery, chemotherapy and radiation therapy or combinations of them. The treatment choice is influenced by tumour variability and prognostic factors, but it also depends on cancer extension, extranodal extension, nervous invasion, human papilloma virus (HPV) presence, making the decisional algorithm not always clear. HPV-related OPSCC is strongly associated with a favourable overall survival (OS) and disease-free survival rate (DSS); by contrast, HPV-negative OPSCC often flags a worse prognosis. Consequently, the Americ...
Surgical Options for Locally Advanced Oropharyngeal Cancer
Current Treatment Options in Oncology, 2019
Oropharyngeal squamous cell carcinoma I Transoral robotic surgery I Transoral laser microsurgery I Human papillomavirus-related cancer Opinion statement Oropharyngeal squamous cell carcinoma (OPSCC) incidence rates have been steadily increasing over the past several decades, and this has been largely attributed to human papillomavirus (HPV)-related OPSCC. The rise of HPV-related OPSCC and the observed distinct survival advantage it offers compared to HPV-unrelated OPSCC have resulted in the development of a new staging system specifically for OPSCC in the eighth edition of the AJCC Staging Manual for head and neck cancer. The observations on HPV-related OPSCC and its prognostic implications have coincided with increasing utilization of transoral surgical approaches to oropharyngeal tumors, such as transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). These approaches were once thought to only be applicable to patients with low T-stage OPSCC tumors; however, they are being increasingly utilized in locally advanced OPSCC cases as several studies have shown that both of these transoral approaches are oncologically sound alternatives to concurrent chemoradiation therapy (CCRT), which was previously the standard-of-choice treatment in patients with locally advanced disease. Moreover, these transoral approaches have displayed better long-term swallowing outcomes compared to CCRT, as severe dysphagia is often the most bothersome functional impairment to OPSCC survivors who have undergone CCRT. While open surgical approaches were previously not utilized in the locally advanced OPSCC setting due to the risk of severe surgical complications compared to the potential benefits of organ preservation with CCRT and comparable survival rates after either treatment regimen, these approaches are still reasonable options for select patients in the salvage surgery setting, as they allow for maximum exposure to the deep oropharyngeal anatomy. Data from multiple clinical trials evaluating the potential for TORS to de-escalate radiation dose or CCRT regimen in certain settings will inform clinical decision-making for OPSCC patients for the next decade and allow for more personalized treatments tailored to an individual patient's disease burden.
Treatment Options in Early Stage (Stage I and II) of Oropharyngeal Cancer: A Narrative Review
Medicina
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. ...
Oropharyngeal Cancer: A Case for Single Modality Treatment With Transoral Laser Microsurgery
Archives of Otolaryngology Head Neck Surgery, 2009
To demonstrate the role of transoral laser microsurgery (TLM) in the treatment of oropharyngeal cancer. Design: A 2-center retrospective case series analysis. Setting: Two tertiary care medical centers. Patients: The study population comprised 69 patients with previously untreated select T1 to T3, N0 to N2 squamous cell carcinoma of the oropharynx, of whom 44 (74%) had no indication for adjuvant RT and 25 (36%) had an indication for adjuvant RT to the neck alone but declined radiotherapy. The primary tumor sites were the tonsil (n=28 [41%]), tongue base (n = 28 [41%]), pharyngeal wall (n = 8 [12%]), soft palate (n = 4 [6%]), and vallecula (n=1 [1%]). Interventions: Transoral laser microsurgery in 69 patients, with neck dissection in 59 patients (83%). Main Outcome Measures: Complications, local and regional control, overall and disease-specific survival, swallow function, and feeding tube dependence. Results: Over the mean follow-up period of 44 months, 66 of 69 patients had no disease recurrence at the primary site. The 5-year local control estimate was 94%. The mean duration of hospitalization was 3 days. There were no major complications relating to TLM. No patient required a permanent feeding or tracheostomy tube. For stage I, II, and III disease, the 5-year Kaplan-Meier estimates of locoregional control were 90%, 73%, and 70%, respectively. The 5-year overall survival estimate was 86%. Conclusions: Transoral laser microsurgery alone with or without neck dissection is an effective approach for select T1 to T3, N0, or N1 oropharyngeal cancer. Low levels of morbidity, short treatment duration, and excellent disease control make it an attractive therapeutic strategy. The treatment option of endoscopic-assisted laser microsurgery should be discussed by the multidisciplinary team for patients presenting with tumors suitable for this approach.
Oropharyngeal cancer: current understanding and management
Current Opinion in Otolaryngology & Head & Neck Surgery, 2009
Purpose of review The goals of this article are: to briefly review oropharyngeal anatomy; to provide a review of the epidemiology of oropharyngeal cancer in the Western Hemisphere; to review the literature on the association of human papilloma virus with oropharyngeal cancer; to review the recent literature on evolving diagnostic techniques for oropharyngeal cancer; and to summarize accepted management strategies for oropharyngeal cancer by subsite. Recent findings The incidence of oropharyngeal cancer may be increasing among younger age groups in the Western Hemisphere, and this may be related to an increased association with human papillomavirus 16. The implications of this viral association with regard to outcomes and management strategies remain under investigation. Screening with toluidine blue, autofluorescence, or both may be useful adjuncts to physical examination and panendoscopy in assessing potentially invasive or dysplastic lesions of the oropharynx. These techniques remain under study. MRI and PET scan are proving to be useful techniques for assessing local extension, regional metastases, and recurrences of squamous cell carcinoma (SCC) of the oropharynx in selected cases. However, serial computed tomography scanning remains the imaging modality of choice in the United States. Early SCCs of the oropharynx (T1-2), in general, may be managed effectively with either surgery or primary irradiation, though, with either technique, clinicians must have a management plan for the neck. Advanced SCCs of the oropharynx (T3-4, nodally aggressive, or both) require multimodal approaches consisting of either surgery along with adjuvant irradiation or concurrent chemoradiation along with salvage surgery (as necessary). Summary Management of SCC of the oropharynx is in a period of transition because of evolving changes in our understanding of the oncogenic process; evolving diagnostic techniques; and evolving combinations of therapies, both surgical and nonsurgical. For the time being, we propose using local subsite and disease stage to guide therapeutic decision-making.
Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment
Cochrane database of systematic reviews (Online)
Oral and oropharyngeal cancers can be managed by surgery alone or with any combination of radiotherapy, chemotherapy and immunotherapy/biotherapy. Opinions on the surgical treatment, the optimal combinational therapy and the sequence of treatments in combinational therapy varies enormously. To determine which surgical treatment modalities for oral and oropharyngeal cancers lead to the best outcomes compared with other surgical, radiotherapy, chemotherapy or immunotherapy/biotherapy combinations. Electronic search of the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE, OLDMEDLINE, EMBASE, AMED and the National Cancer Trials Database. Reference lists from relevant articles were searched and the authors of eligible trials were contacted. Date of the most recent searches: July 2007. Randomised controlled trials of surgery alone or in combination with chemotherapy, radiotherapy or immunotherapy/biotherapy for the treatment of primary oral or oropharyngeal cancer or both. A m...
Head & Neck, 2013
Background-The purpose of this study was to report the treatment outcomes of patients with advanced oropharyngeal cancer treated with transoral laser microsurgery (TLM) followed by radiation therapy (RT) at Mayo Clinic in Arizona. Methods-A retrospective study of 80 patients treated from January 1, 2000 to November 7, 2011 was performed. All patients had stage III/IV oropharyngeal tumors and underwent TLM with neck dissection. Adjuvant RT was then given. Thirty-seven patients received concurrent adjuvant chemotherapy. The primary outcome was locoregional control. Results-Median follow-up was 47.3 months (range, 9.7-139.2 months). The 3-year locoregional control, recurrence-free survival, and overall survival rates were 98.6% (95% confidence interval [CI], 91% to 100%), 91.1% (95% CI, 81% to 96%), and 93.7% (95% CI, 84% to 98%), respectively. There were a total of 5 treatment failures, 1 regional and 4 distant. Twentysix patients underwent neck only RT with exclusion of the primary site. Conclusion-TLM followed by RT for advanced oropharyngeal cancer results in excellent locoregional control rates.
Current trends in initial management of oropharyngeal cancer: the declining use of open surgery
European Archives of Oto-Rhino-Laryngology, 2009
The widespread availability of novel primary treatment approaches against oropharyngeal cancers has provided several potentially curative surgical and nonsurgical treatment options for patients, generating both hope and controversy. As treatment is usually curative in intent, management considerations must include consideration of primary tumor and nodal disease control as well as long-term toxicities and functional outcomes. Anatomical and functional organ preservation (speech and deglutition) remains of paramount importance to patients with oropharyngeal cancer and the physicians involved in their care, accounting for the growing popularity of chemoradiotherapy and transoral surgical techniques for this indication. These novel approaches have greatly diminished the role of open surgery as initial therapy for oropharyngeal cancers. Open surgery which is often reserved for salvage on relapse, may still be an appropriate therapy for certain early stage primary lesions. The growing treatment armamentarium requires careful consideration for optimal individualized care. The identiWcation of oncogenic human papillomavirus as a predictive and prognostic marker in patients with oropharyngeal cancer has great potential to further optimize the choice of treatment. In this review, novel primary therapies against oropharyngeal squamous cell carcinoma are presented in the context of anatomical, quality of life, and emerging biological considerations.
Prognostic factors and survival unique to surgically treated p16+ oropharyngeal cancer
The Laryngoscope, 2012
Objectives/Hypothesis: Current head and neck epidemiology demonstrates a steadily increasing incidence of p16þ human papillomavirus-related oropharynx squamous cell cancer (OPSCC). This distinct tumor subtype is associated with better survival outcomes. There is a growing recognition of the need to define management regimens that take into account the inherent patho-biological attributes of these cancers and provide optimum oncological control with minimum morbidity. This is facilitated by a clear understanding of the prognostic variables that predict disease outcome in patients with p16þ OPSCC. To provide prognostic estimates, pathological staging and histopathological parameters are usually superior to clinical staging. However, knowledge of pathological predictors is sparse, mainly because of commonly employed nonsurgical management policies utilizing chemoradiotherapy. Minimally invasive approaches to the oropharynx, particularly transoral laser microsurgery (TLM), are well-reported effective primary treatments for oropharynx cancers. From such series, it is feasible to conduct a detailed appraisal based on pathologic information from surgical specimens of both the primary and neck, to establish prognosticators unique to p16þ oropharynx cancer patients.