Surgery Versus Radiotherapy for Early Oropharyngeal Tumors: a Never-Ending Debate
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Therapeutic options for early stage oropharyngeal squamous cell carcinoma (OPSCC) include both surgery and radiotherapy as single treatment modality. Retrospective data reporting on locoregional control and survival rates in early stage OPSCC have shown equivalent efficacy, although no prospective randomized trials are available to confirm these results. Given the assumed comparable oncologic results in both groups, complication rates and functional outcomes associated with each modality play a major role when making treatment decisions. Radiotherapy is used preferentially in many centers because few trials have reported higher complication rates in surgical patients. However, these adverse effects were mainly due to traditional invasive open surgical approaches used for access to the oropharynx. In order to decrease the morbidity of these techniques, transoral surgical (TOS) approaches have been developed progressively. They include transoral laser microsurgery (TLM), transoral robotic surgery (TORS), and conventional transoral techniques. Meta-analysis comparing these new approaches with radiotherapy showed equivalent efficacy in terms of oncologic results. Furthermore, studies reporting on functional outcomes in patients undergoing TOS for OPSCC did not show major long-term functional impairment following treatment. Given the abovementioned statements, it is our practice to treat early stage OPSCC as follows: whenever a single modality treatment seems feasible (T1–2 and N0–1), we advocate TOS resection of the primary tumor associated with selective neck dissection, as indicated. In our opinion, the advantage of this approach relies on the possibility to stratify the risk of disease progression based on the pathological features of the tumor. Depending on the results, adjuvant radiation treatment or chemoradiotherapy can be chosen for high-risk patients. For tumors without adverse features, no adjuvant treatment is given. This approach also allows prevention of potential radiation-induced late complications while keeping radiotherapy as an option for any second primary lesions whenever needed. Definitive radiotherapy is generally reserved for selected patients with specific anatomical location associated with poor functional outcome following surgery, such as tumor of the soft palate, or for patients with severe comorbidities that do not allow surgical treatment.
KeywordsOropharyngeal cancer Early stage Trans-oral surgery Radiotherapy Review
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Conflict of Interest
Yan Monnier and Christian Simon declare that they have no conflict of interest.
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This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 2.Sturgis EM, Ang KK. The epidemic of HPV-associated oropharyngeal cancer is here: is it time to change our treatment paradigms? J Natl Compr Cancer Netw. 2011;9(6):665–73.Google Scholar
- 10.•Hinni ML, Zarka MA, Hoxworth JM. Margin mapping in transoral surgery for head and neck cancer. Laryngoscope. 2013;123(5):1190–8. This is an article reporting on the average size of surgical margins and the oncologic outcomes obtained with TLM and margin mapping techniques.PubMedCrossRefGoogle Scholar
- 15.•Quon H. Transoral robotic surgery and adjuvant therapy for oropharyngeal carcinomas and the influence of p16 INK4a on treatment outcomes. Laryngoscope. 2013;123(3):635–40. This is a review reporting on the oncologic outcomes between HPV-positive and HPV-negative OPSCC treated with TORS.PubMedCrossRefGoogle Scholar
- 19.••Morisod, B. and C. Simon, A meta-analysis on survival of patients treated with trans-oral surgery (TOS) versus radiotherapy (RT) for early stage squamous cell carcinoma of the oropharynx (OPSCC). Head Neck, 2014. doi: 10.1002/hed.23995. This is a recent meta-analysis specifically addressing the question of oncologic outcomes in early stages OPSCC. The data show equivalent efficacy of both treatment modalities in terms of disease control.
- 20.••Williams CE et al. Transoral laser resection versus lip-split mandibulotomy in the management of oropharyngeal squamous cell carcinoma (OPSCC): a case match study. Eur Arch Otorhinolaryngol. 2014;271(2):367–72. This is a retrospective study addressing the functional outcomes, rates of complications and cost of TOS approaches, as compared to traditional open surgical treatments of OPSCC.PubMedCrossRefGoogle Scholar
- 21.••Chen AM et al. Comparison of functional outcomes and quality of life between transoral surgery and definitive chemoradiotherapy for oropharyngeal cancer. Head Neck. 2015;37(3):381–5. This is a case control study comparing functional outcomes between TOS approaches and definitive radiotherapy. It shows better recovery of function with TOS.PubMedCrossRefGoogle Scholar
- 27.••Hutcheson KA et al. Functional outcomes after TORS for oropharyngeal cancer: a systematic review. Eur Arch Otorhinolaryngol. 2015;272((2):463–71. This is a recent meta-analysis specifically addressing the question of functional outcomes in OPSCC treated with TORS. It shows overall good functional results and identifies baseline function, TNM stage, primary tumor location in the base of tongue and adjuvant chemo radiation therapy as predictors of poor functional prognosis.PubMedCrossRefGoogle Scholar
- 30.de Almeida, J.R, et al. Transoral robotic surgery is cost-effective compared to (Chemo)radiotherapy for early t-classification oropharyngeal carcinoma: A cost-utility analysis. Head Neck, 2014. doi: 10.1002/hed.23930.
- 36.••Lee SY et al. Comparison of oncologic and functional outcomes after transoral robotic lateral oropharyngectomy versus conventional surgery for T1 to T3 tonsillar cancer. Head Neck. 2014;36(8):1138–45. This is a prospective study reporting on the functional and oncologic outcomes between TORS, conventional TOS approaches and open surgery in the management of OPSCC.It shows better rates of negative margins with TORS and better functional as well as faster recovery times with TOS techniques as compared with open approaches.PubMedCrossRefGoogle Scholar