Advertisement

Surgical Perspective in the Management of Oropharyngeal Cancer

  • Neil Gildener-LeapmanEmail author
  • Seungwon Kim
Chapter
First Online:
  • 754 Downloads

Abstract

Transoral robotic surgery is the primary method for resection of oropharyngeal malignancies when primary chemoradiation is not employed. There are multiple methods of resecting the oropharynx in primary and recurrent disease including open approaches, direct line of sight electrocautery, transoral laser microsurgery (TLM), and transoral robotic surgery (TORS). Details of TORS technique are reviewed from surgical site exposure to steps of resection, hemostasis, and reconstruction. Oncologic outcomes are excellent when TORS is combined with adjuvant therapy as appropriate. Overall two-year survival with TORS is between 82 and 94 % and positive margin rate is approximately 6 %. TORS has a distinct set of complications when compared to chemoradiation, with oropharyngeal hemorrhage being a rare but devastating event. Because oncologic outcomes are excellent in oropharyngeal cancer quality of life (QOL) measures are of primary importance when choosing a treatment modality. New trials are opening to investigate how TORS can play a role in changing QOL outcomes and treatment de-escalation. While treatment principles will remain similar for the foreseeable future, new flexible robotic technology may allow for improved surgical exposure in difficult patients.

Keywords

Oropharyngeal cancer TORS Chemoradiation Quality of life Transoral laser microsurgery Oropharyngeal hemorrhage Local and free-flap reconstruction Recurrent cancer 
This is a preview of subscription content, log in to check access.

References

  1. Arora A et al (2014) Determination of biometric measures to evaluate patient suitability for transoral robotic surgery (tors). Head Neck. doi: 10.1002/hed.23739
  2. Asher SA et al (2013) Hemorrhage after transoral robotic-assisted surgery. Otolaryngol Head Neck Surg 149(1):112–117PubMedCrossRefGoogle Scholar
  3. Calais G et al (1999) Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma. J Natl Cancer Inst 91(24):2081–2086PubMedCrossRefGoogle Scholar
  4. Chia SH, Gross ND, Richmon JD (2013) Surgeon experience and complications with transoral robotic surgery (TORS). Otolaryngol Head Neck Surg 149(6):885–892PubMedCrossRefGoogle Scholar
  5. Cognetti DM et al (2012) Early adoption of transoral robotic surgical program: preliminary outcomes. Otolaryngol Head Neck Surg 147(3):482–488PubMedCrossRefGoogle Scholar
  6. Cohen MA et al (2011) Transoral robotic surgery and human papillomavirus status: oncologic results. Head Neck 33(4):573–580PubMedCrossRefGoogle Scholar
  7. Cooper JS et al (2012) Long-term follow-up of the RTOG 9501/intergroup phase III trial: postoperative concurrent radiation therapy and chemotherapy in high-risk squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 84(5):1198–1205PubMedCentralPubMedCrossRefGoogle Scholar
  8. de Almeida JR et al (2014a) Reconstructive algorithm and classification system for transoral oropharyngeal defects. Head Neck 36:934–941Google Scholar
  9. de Almeida JR et al (2014b) A systematic review of transoral robotic surgery and radiotherapy for early oropharynx cancer: A systematic review. Laryngoscope 124:2096–2102Google Scholar
  10. Dziegielewski PT et al (2013) Transoral robotic surgery for oropharyngeal cancer: long-term quality of life and functional outcomes. JAMA Otolaryngol Head Neck Surg 139(11):1099–1108PubMedCentralPubMedCrossRefGoogle Scholar
  12. Forastiere AA et al (2013) Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol 31(7):845–852PubMedCentralPubMedCrossRefGoogle Scholar
  13. Haughey BH et al (2011) Transoral laser microsurgery as primary treatment for advanced-stage oropharyngeal cancer: a United States multicenter study. Head Neck 33(12):1683–1694PubMedCrossRefGoogle Scholar
  14. Haus BM et al (2003) Surgical robotic applications in otolaryngology. Laryngoscope 113(7):1139–1144PubMedCrossRefGoogle Scholar
  15. Hockstein NG, Weinstein GS, O’Malley BW Jr (2005) Maintenance of hemostasis in transoral robotic surgery. ORL J Otorhinolaryngol Relat Spec 67(4):220–224PubMedCrossRefGoogle Scholar
  16. Johnson PJ et al (2013) Demonstration of transoral surgery in cadaveric specimens with the medrobotics flex system. Laryngoscope 123(5):1168–1172PubMedCrossRefGoogle Scholar
  17. Loevner LA et al (2013) Transoral robotic surgery in head and neck cancer: what radiologists need to know about the cutting edge. Radiographics 33(6):1759–1779PubMedCrossRefGoogle Scholar
  18. Lukens JN et al (2014) Late consequential surgical bed soft tissue necrosis in advanced oropharyngeal squamous cell carcinomas treated with transoral robotic surgery and postoperative radiation therapy. Int J Radiat Oncol Biol Phys 89(5):981–8Google Scholar
  19. Maxwell JH et al (2013) Extracapsular spread in head and neck carcinoma: impact of site and human papillomavirus status. Cancer 119(18):3302–3308Google Scholar
  20. Moore EJ et al (2009) Transoral resection of tonsillar squamous cell carcinoma. Laryngoscope 119(3):508–515PubMedCrossRefGoogle Scholar
  21. Moore EJ, Olsen KD, Martin EJ (2011) Concurrent neck dissection and transoral robotic surgery. Laryngoscope 121(3):541–544PubMedCrossRefGoogle Scholar
  22. Moore EJ, Janus J, Kasperbauer J (2012a) Transoral robotic surgery of the oropharynx: clinical and anatomic considerations. Clin Anat 25(1):135–141PubMedCrossRefGoogle Scholar
  23. Moore EJ et al (2012b) Long-term functional and oncologic results of transoral robotic surgery for oropharyngeal squamous cell carcinoma. Mayo Clin Proc 87(3):219–225PubMedCentralPubMedCrossRefGoogle Scholar
  24. More YI et al (2013) Functional swallowing outcomes following transoral robotic surgery vs primary chemoradiotherapy in patients with advanced-stage oropharynx and supraglottis cancers. JAMA Otolaryngol Head Neck Surg 139(1):43–48PubMedCrossRefGoogle Scholar
  25. Nichols AC et al (2013) Early-stage squamous cell carcinoma of the oropharynx: radiotherapy vs. trans-oral robotic surgery (ORATOR)–study protocol for a randomized phase II trial. BMC Cancer 13:133PubMedCentralPubMedCrossRefGoogle Scholar
  26. Richmon JD et al (2014) Feasibility of rapid discharge after transoral robotic surgery of the oropharynx. Laryngoscope 124(11):2518–25Google Scholar
  27. Weinstein GS et al (2010) 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 120(9):1749–1755PubMedCrossRefGoogle Scholar
  28. White H et al (2013) Salvage surgery for recurrent cancers of the oropharynx: comparing TORS with standard open surgical approaches. JAMA Otolaryngol Head Neck Surg 139(8):773–778PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of OtolaryngologyNew York Eye and Ear Infirmary of Mount SinaiNew York CityUSA
  2. 2.Department of OtolaryngologyEye & Ear Institute, University of PittsburghPittsburghUSA

Personalised recommendations

Cite chapter

Buy options