36
Vol. 66, No. 1 2015
Northeast Florida Medicine
Otolaryngology
In 2008, Dr. Carol Fakhry and her group fromThe Johns
Hopkins University published the results of a prospective
evaluation of therapeutic response and survival among
96 patients with stage III or IV head and neck squamous
cell carcinoma involving the oropharynx and larynx.
6
Patients received two cycles of induction chemotherapy
with paclitaxel and carboplatin followed by concomitant
weekly paclitaxel and standard radiation therapy. Tumors
were analyzed for the presence or absence of HPV. Two
year overall and progression-free survival was estimated
for HPV-positive (HPV+) and HPV-negative (HPV-)
patients. HPV+ patients had statistically significantly
higher response rates to induction chemotherapy and to
concomitant therapy (P = 0.01). They also had statisti-
cally significantly better two-year survival (95 percent vs.
62 percent, P = 0.005). Hong et al
7
showed that HPV+
tumors responded to all forms of treatment better than
HPV- tumors. One hundred ninety five patients with
stage III and IV oropharyngeal squamous cell carcinoma
were included in this retrospective study. HPV status was
determined for all patients. Forty two percent were HPV+.
Patients were further divided into treatment groups. Four-
teen received surgery alone, while 110 received surgery
with post-operative radiation therapy. Twenty four were
treated with radiation therapy alone, and 47 were treated
with radiation therapy and chemotherapy. Loco-regional
recurrence rates and overall survival were analyzed. The
surgery alone group was too small to analyze for HPV
effect. The other groups all showed improved survival for
HPV+ patients regardless of treatment form.
Improved survival of HPV+ patients has led to propos-
als that these tumors could be treated “less aggressively.”
It was speculated that HPV+ tumors might require less
post-op radiation therapy and that chemotherapy could
be avoided in some patients, even in the presence of
extra-capsular nodal extension. Such notions have yet
to be proven and are the subject of prospective trials.
8
Also of note is the suggestion that if these tumors are
HPV- related, vaccination against HPV might prevent
the development of cancers in “at risk” individuals.
9
This
led to recommendations that both males and female be
vaccinated with the quadrivalent vaccine, Gardisil®. Gardi-
sil® protects against the p16 and p18 subtypes associated
with cervical and oropharyngeal carcinoma, as well as p6
and p11 subtype associated with respiratory papillomas
in both children and adults.
Minimally Invasive Surgery
Otolaryngologists have used trans-oral surgical techniques
since the 1920s to eradicate lesions of the aerodigestive
tract. Recently, investigators have expanded use of these
techniques to include treatment of oral cavity, oropha-
ryngeal and hypopharyngeal tumors. Instrumentation
was augmented, and lasers were adapted for use in these
trans-oral tumor extractions. Known as “Trans-oral Laser
Microresection” or “TLM,” this technique was developed in
Europe and brought to the U.S. in the 1990s.
10
Oncologic
results have been excellent.
In 2011, Dr. Bruce Haughey from the University of
Washington School of Medicine in St. Louis published a
study involving 204 patients with stage III and IV cancer
involving the tonsil and the base of tongue treated with
TLM. The study was conducted across three sites, and
included patients treated between 1996 and 2006. Three
year overall survival was 86 percent. Disease specific survival
was 88 percent. Disease free survival was 82 percent. Local
control of tumor was achieved in 97 percent. Eighty seven
percent of patients had normal swallowing at the end of
the study.
11
Advantages of TLM include:
• no need for tracheotomy in most cases
• elimination of the need for elaborate flap reconstruction
• decreased hospital stay
• rapid return to normal swallowing function
The key to the success of this technique is proper
patient selection.
The DaVinci Surgical Robot has also been applied to
the treatment of selected head and neck cancers. In 2005,
Dr. Gregory Weinstein of the University of Pennsylvania,
introduced the use of the DaVinci robot for treatment of
head and neck tumors by reporting on a supraglottic lar-
yngectomy successfully performed in a canine model.
12
The
use of angled telescopes, highly flexible articulated arms,
and the adaptability to flexible laser fiber technology has
allowed head and neck surgeons safe access to previously
difficult to reach tumors. Initial robotic experience in hu-
mans was confined to small tumors, usually in the tonsil.
Subsequently, robotic techniques have been expanded
allowing surgeons to successfully operate on tumors in
the base of tongue, oropharynx and the larynx. Published
reports have validated the technique, known as TORS
(TransOral Robotic Surgery), citing decreased length of
stay, less pain, faster return of swallowing function and
excellent oncologic results.
13
BothTLMandTORS have given head and neck surgeons
new tools and techniques to provide options for selected
patients that result in excellent tumor control while min-
imizing toxicity and long-term morbidity of treatment.
