Head and neck cancers are a heterogeneous collection of malignancies of the upper aerodigestive tract, salivary glands and thyroid. In this Review, we primarily focus on the changing therapeutic landscape of head and neck squamous cell carcinomas (HNSCCs) that can arise in the oral cavity, oropharynx, hypopharynx and larynx. We highlight developments in surgical and non-surgical therapies (mainly involving the combination of radiotherapy and chemotherapy), outlining how these treatments are being used in the current era of widespread testing for the presence of human papillomavirus infection in patients with HNSCC. Finally, we describe the clinical trials that led to the approval of the first immunotherapeutic agents for HNSCC, and discuss the development of strategies to decrease the toxicity of different treatment modalities.

The changing therapeutic landscape of head and neck cancer.

Context Human papillomavirus (HPV) is a major cause of oropharyngeal squamous cell carcinomas, and HPV (and/or surrogate marker p16) status has emerged as a prognostic marker that significantly impacts clinical management. There is no current consensus on when to test oropharyngeal squamous cell carcinomas for HPV/p16 or on which tests to choose. Objective To develop evidence-based recommendations for the testing, application, interpretation, and reporting of HPV and surrogate marker tests in head and neck carcinomas. Design The College of American Pathologists convened a panel of experts in head and neck and molecular pathology, as well as surgical, medical, and radiation oncology, to develop recommendations. A systematic review of the literature was conducted to address 6 key questions. Final recommendations were derived from strength of evidence, open comment period feedback, and expert panel consensus. Results The major recommendations include (1) testing newly diagnosed oropharyngeal squamous cell ca...

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Human papillomavirus testing in head and neck carcinomas guideline from the college of American pathologists

ObjectiveThe near epidemic rise of the incidence of human papillomavirus (HPV)-related oropharyngeal squamous cell carcinomas (OPSCC) presents the practitioner with a “new” head and neck cancer patient, vastly different from those with the traditional risk factors who formed the basis of most practitioners’ training experience. Accordingly, a thorough and disease-specific evaluation process is necessitated. This article will review the evaluation of the HPV-related cancer patient, including a review of the HPV-positive oropharyngeal cancer epidemic from the surgeon’s perspective, evaluation of the primary lesion, evaluation of the neck mass, and role of imaging, to provide a framework for addressing the challenging questions patients may ask.Data SourcesAvailable peer-reviewed literature and practice guidelines.Review MethodsAssessment of selected specific topics by authors solicited from the Head and Neck Surgery and Oncology Committee of the American Academy of Otolaryngology—Head and Neck Surgery Found...

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The "new" head and neck cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation.

Head and neck cancer is a heterogenous group of cancers involving the upper aerodigestive tract. In this review article, the most common sites will be discussed, including the oral cavity, oropharynx, hypopharynx, and larynx. Etiology and epidemiology will be discussed followed by staging, treatment, and survival.

Current treatment of head and neck squamous cell cancer

Transoral endoscopic head and neck surgery is a new approach for the treatment of oropharyngeal tumors. Using either a robotic system and/or laser, surgeons gain access through the mouth via minimally invasive technique and thus have improved visualization of the tumors of the oropharynx, without disfiguring incisions. This transoral route of access minimizes long-term speech and swallowing dysfunction. Surgeons view this approach as a considerable technologic advance, analogous to the evolution in radiation therapy from conventional two- and three-dimensional conformal techniques to intensity-modulated techniques. Although the use of radiation with or without chemotherapy to treat oropharyngeal cancer (OPC) is supported by evidence from prospective clinical trials, there are no prospective data supporting the use of this new surgical approach for OPC. Here, we review the fundamentals of transoral endoscopic head and neck surgery, with robotics and laser technology, and discuss ongoing clinical trials for patients with OPC.

Transoral Endoscopic Head and Neck Surgery and Its Role Within the Multidisciplinary Treatment Paradigm of Oropharynx Cancer: Robotics, Lasers, and Clinical Trials

Importance Because treatment for oropharyngeal squamous cell carcinoma (OPSCC), especially in patients of older age, is associated with decreased patient quality of life (QOL) after surgery, demonstration of a less QOL-impairing treatment technique would improve patient satisfaction substantially. Objective To determine swallowing, speech, and QOL outcomes following transoral robotic surgery (TORS) for OPSCC. Design, Participants, and Setting This prospective cohort study of 81 patients with previously untreated OPSCC was conducted at a tertiary care academic comprehensive cancer center. Interventions Primary surgical resection via TORS and neck dissection as indicated. Main Outcomes and Measures Patients were asked to complete the Head and Neck Cancer Inventory (HNCI) preoperatively and at 3 weeks as well as 3, 6, and 12 months postoperatively. Swallowing ability was assessed by independence from a gastrostomy tube (G-tube). Clinicopathologic and follow-up data were also collected. Results Mean follow-up time was 22.7 months. The HNCI response rates at 3 weeks and 3, 6, and 12 months were 79%, 60%, 63%, and 67% respectively. There were overall declines in speech, eating, aesthetic, social, and overall QOL domains in the early postoperative periods. However, at 1 year post TORS, scores for aesthetic, social, and overall QOL remained high. Radiation therapy was negatively correlated with multiple QOL domains (P  1 oropharyngeal site resected) and age older than 55 years predicted the need for a G-tube at any point after TORS (P  Conclusions and Relevance Patients with OPSCC treated with TORS maintain a high QOL at 1 year after surgery. Adjuvant treatment and older age tend to decrease QOL. Patients meeting these criteria should be counseled appropriately.

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Transoral Robotic Surgery for Oropharyngeal Cancer: Long Term Quality of Life and Functional Outcomes

Background

Transoral, minimally invasive organ preservation surgeries are being increasingly used for laryngopharyngeal carcinomas to avoid the toxicities of combined chemotherapy and radiation therapy regimens. This study investigates the efficiency, safety, and functional outcomes of transoral robotic surgery (TORS) supraglottic laryngectomy.



Methods

Patients with laryngeal cancer who underwent TORS supraglottic laryngectomy and participated in a prospective TORS study between 2008 and 2011 at an academic medical center are presented.



Results

Thirteen of 126 patients underwent TORS supraglottic laryngectomy for laryngeal cancer. Average robotic operative time and estimated blood loss were 25.3 minutes and 15.4 mL, respectively. Negative surgical margins were achieved in all patients. Eleven patients were started on an oral diet within 24 hours of surgery with no evidence of immediate airway compromise. Two patients (15.4%) received adjuvant radiation therapy based on pathology.



Conclusion

In this preliminary study, TORS supraglottic laryngectomy was a safe procedure with good functional outcomes. © 2012 Wiley Periodicals, Inc. Head Neck, 2013

Clinical outcomes of transoral robotic supraglottic laryngectomy.

Background
The management of carcinoma of unknown primary (CUP) is one of the challenging conditions in head and neck oncologic surgery. Despite various diagnostic tools, the primary tumor site in more than half of cases remains unidentified. The purpose of this study was to assess the feasibility and efficiency of utilizing transoral robotic surgery (TORS) for the diagnosis and treatment of CUP in the head and neck.

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Transoral robotic approach to carcinoma of unknown primary.

Background

Oncologic resection of the clivus, nasopharynx, craniovertebral junction, and infratemporal fossa is a challenging endeavor because of their complex and protected anatomy. Our goals were to design a cadaveric model and identify advantages and limitations of combining the transoral robotic surgery (TORS) and endoscopic endonasal approach (EEA) techniques.



Methods

Cadaveric specimens were dissected using a da Vinci surgical robot and endoscopic endonasal instruments in a fashion that mimicked our operating room environment. We then applied these techniques clinically.



Results

EEA was performed to provide a detailed dissection of the infratemporal fossa, nasopharynx, posterior skull base (clivus), and craniovertebral junction. Using TORS, we dissected the parapharyngeal space, infratemporal fossa, and nasopharynx below the eustachian tube, which represented a transition zone that delineated the most effective resection field of each approach.



Conclusions

TORS and EEA seem to be complementary techniques; thus, their combined use seems advantageous for selected advanced tumors in these complex areas. © 2013 Wiley Periodicals, Inc. Head Neck, 35: E351–E358, 2013

Combined transoral robotic surgery and endoscopic endonasal approach for the resection of extensive malignancies of the skull base

Currently, transoral robotic surgery (TORS) with the daVinci robot is mainly used for squamous cell carcinoma of the oropharynx and supraglottic larynx. The safety, efficacy, and functional outcomes regarding this approach have previously been described. In addition to transoral resection of squamous cell carcinoma, we have found use for this technique in removing selected tumors of the parapharyngeal space. Three patients with benign or malignant tumors of the parapharyngeal space who underwent successful transoral resection using the daVinci robot were included in the study. In all three cases, complete tumor excision was achieved without any complication. None required conversion to an open procedure. Mean TORS operative time and intraoperative blood loss were 16.3 min and 4.7 mL, respectively. Inadequate oral exposure, involvement of the internal carotid artery, limited cervical spine mobility and large tumor size are the main limitations of this approach. Result indicates that magnified view, 3D visualization with the combination of the transoral robotic experience, allow en bloc resection of selected parapharyngeal space tumors located medial to the carotid sheath.

Kasim Durmus

Papers

Transoral Robotic Surgery for Oropharyngeal Cancer: Long Term Quality of Life and Functional Outcomes

Clinical outcomes of transoral robotic supraglottic laryngectomy.

Transoral robotic approach to carcinoma of unknown primary.

Combined transoral robotic surgery and endoscopic endonasal approach for the resection of extensive malignancies of the skull base

Transoral robotic resection of selected parapharyngeal space tumors