Surgical Options for Locally Advanced Oropharyngeal Cancer

  • Hannan A. Qureshi
  • Marianne Abouyared
  • Brittany Barber
  • Jeffrey J. HoultonEmail author
Head and Neck Cancer (CP Rodriguez, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Head and Neck 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.


Oropharyngeal squamous cell carcinoma Transoral robotic surgery Transoral laser microsurgery Human papillomavirus-related cancer 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424.CrossRefGoogle Scholar
  2. 2.
    Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29(32):4294–301.CrossRefGoogle Scholar
  3. 3.
    Chaturvedi AK, Engels EA, Anderson WF, Gillison ML. Incidence trends for human papillomavirus-related and -unrelated oral squamous cell carcinomas in the United States. J Clin Oncol. 2008;26(4):612–9.CrossRefGoogle Scholar
  4. 4.
    Ryerson AB, Peters ES, Coughlin SS, Chen VW, Gillison ML, Reichman ME, et al. Burden of potentially human papillomavirus-associated cancers of the oropharynx and oral cavity in the US, 1998–2003. Cancer. 2008;113(10 Suppl):2901–9.CrossRefGoogle Scholar
  5. 5.
    •• Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, et al. Head and neck cancers—major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(2):122–37 Introduced major changes to the clinical and pathologic staging of oropharyngeal cancers.CrossRefGoogle Scholar
  6. 6.
    Allal AS, Nicoucar K, Mach N, Dulguerov P. Quality of life in patients with oropharynx carcinomas: assessment after accelerated radiotherapy with or without chemotherapy versus radical surgery and postoperative radiotherapy. Head Neck. 2003;25(10):833–9 discussion 9–40.CrossRefGoogle Scholar
  7. 7.
    Calais G, Alfonsi M, Bardet E, Sire C, Germain T, Bergerot P, et al. Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma. J Natl Cancer Inst. 1999;91(24):2081–6.CrossRefGoogle Scholar
  8. 8.
    Wendt TG, Grabenbauer GG, Rödel CM, Thiel HJ, Aydin H, Rohloff R, et al. Simultaneous radiochemotherapy versus radiotherapy alone in advanced head and neck cancer: a randomized multicenter study. J Clin Oncol. 1998;16(4):1318–24.CrossRefGoogle Scholar
  9. 9.
    Brizel DM, Albers ME, Fisher SR, Scher RL, Richtsmeier WJ, Hars V, et al. Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer. N Engl J Med. 1998;338(25):1798–804.CrossRefGoogle Scholar
  10. 10.
    Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper JS, et al. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. J Clin Oncol. 2008;26(21):3582–9.CrossRefGoogle Scholar
  11. 11.
    Mirghani H, Blanchard P. Treatment de-escalation for HPV-driven oropharyngeal cancer: where do we stand? Clin Transl Radiat Oncol. 2018;8:4–11.CrossRefGoogle Scholar
  12. 12.
    Masterson L, Moualed D, Liu ZW, Howard JE, Dwivedi RC, Tysome JR, et al. De-escalation treatment protocols for human papillomavirus-associated oropharyngeal squamous cell carcinoma: a systematic review and meta-analysis of current clinical trials. Eur J Cancer. 2014;50(15):2636–48.CrossRefGoogle Scholar
  13. 13.
    Chen AM, Felix C, Wang PC, Hsu S, Basehart V, Garst J, et al. Reduced-dose radiotherapy for human papillomavirus-associated squamous-cell carcinoma of the oropharynx: a single-arm, phase 2 study. Lancet Oncol. 2017;18(6):803–11.CrossRefGoogle Scholar
  14. 14.
    Strong MS, Jako GJ, Vaughan CW, Healy GB, Polanyi T. The use of CO2 laser in otolaryngology: a progress report. Trans Sect Otolaryngol Am Acad Ophthalmol Otolaryngol. 1976;82(5):595–602.PubMedGoogle Scholar
  15. 15.
    Steiner W, Fierek O, Ambrosch P, Hommerich CP, Kron M. Transoral laser microsurgery for squamous cell carcinoma of the base of the tongue. Arch Otolaryngol Head Neck Surg. 2003;129(1):36–43.CrossRefGoogle Scholar
  16. 16.
    Haughey BH, Hinni ML, Salassa JR, Hayden RE, Grant DG, Rich JT, et al. Transoral laser microsurgery as primary treatment for advanced-stage oropharyngeal cancer: a United States multicenter study. Head Neck. 2011;33(12):1683–94.CrossRefGoogle Scholar
  17. 17.
    Rich JT, Milov S, Lewis JS, Thorstad WL, Adkins DR, Haughey BH. Transoral laser microsurgery (TLM) +/- adjuvant therapy for advanced stage oropharyngeal cancer: outcomes and prognostic factors. Laryngoscope. 2009;119(9):1709–19.CrossRefGoogle Scholar
  18. 18.
    Rich JT, Liu J, Haughey BH. Swallowing function after transoral laser microsurgery (TLM) ± adjuvant therapy for advanced-stage oropharyngeal cancer. Laryngoscope. 2011;121(11):2381–90.CrossRefGoogle Scholar
  19. 19.
    Shiley SG, Hargunani CA, Skoner JM, Holland JM, Wax MK. Swallowing function after chemoradiation for advanced stage oropharyngeal cancer. Otolaryngol Head Neck Surg. 2006;134(3):455–9.CrossRefGoogle Scholar
  20. 20.
    Weinstein GS, O’Malley BW, Hockstein NG. Transoral robotic surgery: supraglottic laryngectomy in a canine model. Laryngoscope. 2005;115(7):1315–9.CrossRefGoogle Scholar
  21. 21.
    Weinstein GS, O’Malley BW, Magnuson JS, Carroll WR, Olsen KD, Daio L, et al. Transoral robotic surgery: a multicenter study to assess feasibility, safety, and surgical margins. Laryngoscope. 2012;122(8):1701–7.CrossRefGoogle Scholar
  22. 22.
    Bhayani MK, Holsinger FC, Lai SY. A shifting paradigm for patients with head and neck cancer: transoral robotic surgery (TORS). Oncology (Williston Park). 2010;24(11):1010–5.Google Scholar
  23. 23.
    Weinstein GS, O’Malley BW, Rinaldo A, Silver CE, Werner JA, Ferlito A. Understanding contraindications for transoral robotic surgery (TORS) for oropharyngeal cancer. Eur Arch Otorhinolaryngol. 2015;272(7):1551–2.CrossRefGoogle Scholar
  24. 24.
    • de Almeida JR, Byrd JK, Wu R, Stucken CL, Duvvuri U, Goldstein DP, et al. A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: a systematic review. Laryngoscope. 2014;124(9):2096–102 A large systematic review comparing effectiveness of TORS versus IMRT for early T-stage oropharyngeal cancer.CrossRefGoogle Scholar
  25. 25.
    Weinstein GS, O’Malley BW, Cohen MA, Quon H. Transoral robotic surgery for advanced oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2010;136(11):1079–85.CrossRefGoogle Scholar
  26. 26.
    Weinstein GS, Quon H, O’Malley BW, Kim GG, Cohen MA. Selective neck dissection and deintensified postoperative radiation and chemotherapy for oropharyngeal cancer: a subset analysis of the University of Pennsylvania transoral robotic surgery trial. Laryngoscope. 2010;120(9):1749–55.CrossRefGoogle Scholar
  27. 27.
    Starmer HM, Quon H, Kumar R, Alcorn S, Murano E, Jones B, et al. The effect of radiation dose on swallowing: evaluation of aspiration and kinematics. Dysphagia. 2015;30(4):430–7.CrossRefGoogle Scholar
  28. 28.
    Wilson JA, Carding PN, Patterson JM. Dysphagia after nonsurgical head and neck cancer treatment: patients’ perspectives. Otolaryngol Head Neck Surg. 2011;145(5):767–71.CrossRefGoogle Scholar
  29. 29.
    Dziegielewski PT, Teknos TN, Durmus K, Old M, Agrawal A, Kakarala K, et al. Transoral robotic surgery for oropharyngeal cancer: long-term quality of life and functional outcomes. JAMA Otolaryngol Head Neck Surg. 2013;139(11):1099–108.CrossRefGoogle Scholar
  30. 30.
    Kelly JR, Park HS, An Y, Contessa JN, Yarbrough WG, Burtness BA, et al. Comparison of survival outcomes among human papillomavirus-negative cT1-2 N1-2b patients with oropharyngeal squamous cell cancer treated with upfront surgery vs definitive chemoradiation therapy: an observational study. JAMA Oncol. 2017;3(8):1107–11.CrossRefGoogle Scholar
  31. 31.
    Kelly JR, Park HS, An Y, Yarbrough WG, Contessa JN, Decker R, et al. Upfront surgery versus definitive chemoradiotherapy in patients with human papillomavirus-associated oropharyngeal squamous cell cancer. Oral Oncol. 2018;79:64–70.CrossRefGoogle Scholar
  32. 32.
    Butlin HT. Diseases of the tongue. London: Cassel & Company; 1885. p. 324–32.Google Scholar
  33. 33.
    Trotter W. A method of lateral pharyngotomy for the exposure of large growths of the epilaryngeal region. Proc R Soc Med. 1920;13(Laryngol Sect):196–8.PubMedPubMedCentralGoogle Scholar
  34. 34.
    Dziegielewski PT, Mlynarek AM, Dimitry J, Harris JR, Seikaly H. The mandibulotomy: friend or foe? Safety outcomes and literature review. Laryngoscope. 2009;119(12):2369–75.CrossRefGoogle Scholar
  35. 35.
    Parsons JT, Mendenhall WM, Stringer SP, Amdur RJ, Hinerman RW, Villaret DB, et al. Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both. Cancer. 2002;94(11):2967–80.CrossRefGoogle Scholar
  36. 36.
    Mendenhall WM, Amdur RJ, Stringer SP, Villaret DB, Cassisi NJ. Radiation therapy for squamous cell carcinoma of the tonsillar region: a preferred alternative to surgery? J Clin Oncol. 2000;18(11):2219–25.CrossRefGoogle Scholar
  37. 37.
    Laccourreye O, Benito J, Menard M, Garcia D, Malinvaud D, Holsinger C. Lateral pharyngotomy for selected invasive squamous cell carcinoma of the lateral oropharynx—part I: how. Laryngoscope. 2013;123(11):2712–7.CrossRefGoogle Scholar
  38. 38.
    Pang P, Li RW, Shi JP, Xu ZF, Duan WY, Liu FY, et al. A comparison of mandible preservation method and mandibulotomy approach in oral and oropharyngeal cancer: a meta-analysis. Oral Oncol. 2016;63:52–60.CrossRefGoogle Scholar
  39. 39.
    Goodwin WJ. Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means? Laryngoscope. 2000;110(3 Pt 2 Suppl 93):1–18.CrossRefGoogle Scholar
  40. 40.
    Röösli C, Studer G, Stoeckli SJ. Salvage treatment for recurrent oropharyngeal squamous cell carcinoma. Head Neck. 2010;32(8):989–96.CrossRefGoogle Scholar
  41. 41.
    Patel SN, Cohen MA, Givi B, Dixon BJ, Gilbert RW, Gullane PJ, et al. Salvage surgery for locally recurrent oropharyngeal cancer. Head Neck. 2016;38(Suppl 1):E658–64.CrossRefGoogle Scholar
  42. 42.
    • Owadally W, Hurt C, Timmins H, Parsons E, Townsend S, Patterson J, et al. PATHOS: a phase II/III trial of risk-stratified, reduced intensity adjuvant treatment in patients undergoing transoral surgery for human papillomavirus (HPV) positive oropharyngeal cancer. BMC Cancer. 2015;15:602 A multicenter phase II/III randomized controlled trial stratifying patients with HPV-positive OPSCC undergoing TORS resection into groups based on pathological risk factors for recurrence for adjuvant treatment.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Hannan A. Qureshi
    • 1
  • Marianne Abouyared
    • 1
  • Brittany Barber
    • 1
  • Jeffrey J. Houlton
    • 1
    Email author
  1. 1.Department of Otolaryngology-Head and Neck SurgeryUniversity of WashingtonSeattleUSA

Personalised recommendations