Summary
Therapy of oropharyngeal squamous cell cancer traditionally has been radiation-based, with surgery mainly in reserve. With increasing depth of local infiltration and volume of regional metastases the role of surgery in safeguarding curative chances increases. However, after failed chemoradiation of oropharynx cancer, few patients are cured by salvage surgery. Thus, primary surgery with postoperative radiotherapy may be contemplated if circumtances are favorable. The oropharynx can be approached by transoral, transmandibular or transcervical routes. Primary surgery is increasingly valuable when resultant morbidity is decreased as in the case of more elaborated transoral approaches. Classical approaches also have improved with increasing use of midline mandibulotomy, marginal mandibulectomy, reconstructive surgery, selective neck dissection (ND), and rehabilitation. Elective ND is restricted to levels I or II to III or IV, therapeutic ND is comprehensive (classic or modified radical depending on capsular integrity), and salvage ND is individualized. Surgery, most often followed by radiotherapy, in selected cases of oropharynx cancer is an interesting alternative to chemoradiation, and in advanced disease a facultative but essential part of multimodal therapy.
Zusammenfassung
Die Therapie des Oropharynxkarzinoms ist traditionell eine Domäne der Strahlentherapie. Der Beitrag der Chirurgie liegt dabei vorwiegend in der Entfernung von Residuen bzw. Rezidiven. Je ausgeprägter die lokale Tiefeninfiltration oder die regionäre Metastasierung, umso höher wird bei gegebener Operabilität der Stellenwert einer Resektion im oft mutimodalen Therapiekonzept. Eine "Rettungschirurgie" bei Rezidiven radiochirurgisch behandelter Oropharynxkarzinome kommt allerdings nur einer Minderheit von Patienten zugute. Primär chirurgische Therapien sollten bei günstigen Rahmenbedingungen daher nicht außer Acht gelassen werden. Chirurgische Zugänge zum Oropharynx sind transoral, transmandibulär oder transzervikal. Eine primäre Resektion, meist mit postoperativer Bestrahlung, hat dort einen zunehmenden Stellenwert, wo sie die Morbidität reduziert, etwa bei weiterentwickelten transoralen Zugängen. Auch die klassischen Zugänge werden durch Mittellinien-Mandibulotomie, marginale Mandibulektomie, plastische Defektrekonstruktion, abgestufte Neck dissection (ND) und logopädische Rehabilitation besser vertragen. Die elektive ND wird selektiv (Levels II–III bis I–IV), die therapeutische ND radikal (modifiziert bei Knoten unter 3 cm) und die posttherapeutische ND individualisiert durchgeführt. Chirurgische Therapien bilden bei ausgewählten Formen des Oropharynxkarzinoms eine interessante Alternative zur Chemoradiotherapie und bei fortgeschrittenen Erkrankungen einen fakultativen, aber wesentlichen Bestandteil multimodaler Therapien.
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Swoboda, H. Indikationen zur chirurgischen Therapie des Oropharynxkarzinoms. Wien Med Wochenschr 158, 249–254 (2008). https://doi.org/10.1007/s10354-008-0529-8
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DOI: https://doi.org/10.1007/s10354-008-0529-8