Minimally Invasive Surgeries Retain Place in Treatment Plan

Robert L. Ferris, MD, PhD

Chief, Division of Head and Neck Surgery, Professor, Otolaryngology and Immunology, Director, Fellowship in Advanced Head and Neck Oncologic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA

In an era when advances in chemoradiation and targeted therapies have revolutionized treatment in head and neck oncology patients, it’s possible that treating physicians might not know where surgery fits into the regimen. However, minimally invasive techniques are allowing for more accurate and less disfiguring options for operating directly on certain tumors, and surgical oncologists, radiation oncologists, and other specialists can work together to deliver the best care to the patient.

That’s the message that Robert L. Ferris, MD, PhD, chief of the Division of Head and Neck Surgery at the University of Pittsburgh Cancer Institute, delivered to oncology professionals at the 7th Annual Multidisciplinary Symposium on Head and Neck Cancer, held in Philadelphia, Pennsylvania, on November 19.

“Minimally invasive surgery is like the ultimate targeted therapy,” Ferris said. Current minimal-access surgical procedures include transoral laser microsurgery (TLM), endoscopic skull base/ endoneurosurgery, selective neck dissection (now sentinel node biopsy), and robotic surgery of the oropharynx and larynx.

In TLM, the surgeon utilizes a microscope and laser to operate directly on tumors in the neck and throat without having to open the neck for surgery. This surgery is particularly effective for operating on a glottic mass and preserving the patient’s ability to speak and swallow after surgery, Ferris said.

A study in Archives of Otolaryngology — Head and Neck Surgery in 2007 investigated the effectiveness of TLM in 117 patients with advanced laryngeal cancer, either stage III or stage IV disease, with a median follow-up of 5 years.¹ After 2 years, the local control rate was 82% and the locoregional control rate was 77%. A total of 92% of patients had an intact larynx, and 68% had achieved disease-free survival. Overall survival at 2 years was 75%. The 5-year Kaplan-Meier estimates were local control, 74%; locoregional control, 68%; disease-free survival, 58%; and overall survival, 55%.

One of the major challenges in patients with laryngeal cancer, according to Ferris, is that there is currently no effective radiographic technique for staging cancer in the neck. “In untreated patients, PET scans yield too many false-positives and false-negatives,” he said. Accurate staging is important because earlier stages might respond better to chemotherapy than surgery, and the opposite could be true of later stages. Better diagnostic techniques would allow for a personalized approach using chemotherapy, radiation, surgery, or a combination of techniques.

Rationale for Transoral Robotic Surgery (TORS) Trial

Key Points

Human papillomavirus (HPV)-positive oropharyngeal cancer rising 5% to 7% every year over past 15 to 20 years

Acute and long-term toxicity in a younger HPV-positive group warrants re-evaluation of therapeutic approach; robotic surgery is feasible and safe (FDA approved)

Trials to demonstrate equivalent outcome with reduced radiation or chemotherapy are ongoing

Surgical staging can personalize therapy, which should reduce permanent treatment-related morbidity through de-intensification of therapy in pathologically confirmed low-risk disease

Source: Park YM et al. J Laparoendosc Adv Surg Tech A. 2009;19(3):361-368.

One solution is use of partial laryngectomy, which allows for pathologic staging, repetition of the surgery if needed, and use of lasers and radiation therapy afterward. However, a partial laryngectomy might require 2 procedures and may not address tumor masses in the neck. And although partial laryngectomy allows for radiation therapy and chemoradiation therapy, some patients may need those treatments no matter what type of surgery they undergo.

Human papillomavirus (HPV) has played a key role in the increasing incidence of head and neck cancer over the past 20 years. Because patients with HPV-positive oropharyngeal cancer tend to be younger, acute and long-term toxicity from treatments are more of a concern, and a re-evaluation of therapeutic approaches is in order, Ferris said.

Robotic surgery is feasible and safe in this patient population, and is FDA-approved. The Transoral Robotic Surgery (TORS) trial looked at the use of a robotic surgical system in laryngeal and hypopharyngeal cancer.² Trials to demonstrate equivalent outcomes with reduced radiation or chemotherapy are ongoing. Surgical staging to pathologically confirm disease stage will be key to appropriate and personalized use of such therapy.

In summary, minimally invasive surgery as the primary intervention can improve staging and help guide subsequent treatment decisions, and shows promise for long-term survival, said Ferris. These types of surgeries enable better staging of the disease for appropriate use of adjuvant therapy. Better surgical techniques also allow for better control on surgical margins, and selective dissections allow a patient to be treated without raising the risk of morbidity due to complications.

References

1. Hinni M, Salassa JR, Grant DG, et al. Transoral laser microsurgery for advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2007;133(12):1198-1204.
2. Park YM, Lee WJ, Lee JG, et al. Transoral robotic surgery (TORS) in laryngeal and hypopharyngeal cancer. J Laparoendosc Adv Surg Tech A. 2009;19(3):361-368.