Transoral Surgery for Oropharyngeal Carcinoma: Eric J. Moore, MD (Mayo Clinic)
Oropharyngeal carcinoma is being diagnosed with increasing frequency throughout the world, afflicts a young and otherwise health patient population, and it presents a considerable management problem for the patient and their physician. Treatment options include both surgical, nonsurgical, and combinations of the two main groups. Surgical treatment can range from simple tonsillectomy to mandibulotomy combined with oropharyngectomy and microvascular reconstruction. The extent of surgical treatment utilized is based largely on the local extent of the tumor. Nonsurgical treatment can range from primary radiation treatment (RT) to combined chemoradiation therapy based on the stage of disease and functional status of the patient. Despite the vast number of articles reviewing the oncologic outcomes and functional results of various treatments for oropharyngeal carcinoma, no definite consensus exists as to the superiority of one treatment over another.
Most authors have advocated primary radiotherapy for early stage disease and combined therapy for advanced stage tonsillar SCCA. Fewer centers recommend primary surgical therapy for early stage tonsillar cancer. This treatment recommendation may range from simple tonsillectomy to wide oropharyngectomy to composite mandibular and tonsillar resection. Other authors have recommended primary radiotherapy or chemoradiotherapy for both early and late stage disease, believing that the oncologic and functional results are similar, but that the severe complication rate is higher for surgical therapy. Ideally, patients could be randomized into one of two treatment groups to definitively evaluate treatment differences, but to date, only one small trial with 70 patients has attempted to investigate these treatment differences in a randomized, prospective manner. This study found no significant differences in survival for surgery, combined therapy, or primary radiotherapy, but it has been criticized as being underpowered. Because of the difficulties in randomizing patients with a life threatening malignancy into a treatment arm that is mired in controversy, it is doubtful that this study will ever be repeated.
Our institution has taken a considerable interest in developing experience in transoral sugery for oropharyngeal neoplasms. Over several decades we have studied and documented our experience in transoral oropharyngectomy. Initially we performed most of these surgeries with transoral cautery, then with microlaryngoscopy and carbon dioxide laser, and most recently we have utilized transoral robotic assistance to access oropharyngeal tumors. We have found that transoral surgery offers high oncologic efficacy in selected patients, and that the functional recover of speech and swallowing post-treatment has been superior to many other traditional methods of oropharyngeal cancer treatment.1,2
The investigation of novel therapies in head and neck cancer must hold up to rigorous analysis of both oncologic value over time and quality of life effects. The head and neck surgeon has a unique opportunity and responsibility to develop and assess therapeutic advances.
2 Transoral robotic surgery for oropharyngeal neoplasms Moore EJ, Olsen KD, Kasperbauer JL. Laryngoscope. 2009 epub.
