Surgery in Oropharyngeal Cancer When is it appropriate?€¦ · Johan Fagan Division of...

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Surgery in Oropharyngeal Cancer

When is it appropriate?

Johan Fagan

Division of Otolaryngology

University of Cape Town

South Africa

Nothing to declare

Oropharynx

• Breathing

• Swallowing

• Speech

• Nasopharyngeal competence

• Smoking

• Alcohol

• Human papilloma virus

– 70% OPC in USA

– >90% HPV 16,18

– Tonsillar crypts without epithelial dysplasia

Africa?

Faggons CE, Mabedi CE et al. Human papillomavirus in head and neck squamous cell carcinoma: A descriptive study of histologically confirmed cases at Kamuzu Central Hospital in Lilongwe, Malawi. Malawi Med J. 2017 Jun; 29(2): 142–5

• Extremely high HPV-related cervical cancer burden

• Bulky tumours….difficult to assign origin as OP or OCSite Number P 16+

Oropharynx/oral cavity 23 5 22%

Blumberg J, Monjane L et al. Investigation of the presence of HPV related oropharyngeal and oral tongue squamous cell carcinoma in Mozambique. Cancer

Epidemiol. 2015 Dec;39(6):1000-5

• Extremely high levels of HPV+ cervical cancer

• 22 OPC SCC

• None of stained positively for p16

Paquette C, Evans MF et al. Evidence that Alpha-9 Human Papillomavirus Infections are a Major Etiologic Factor for Oropharyngeal Carcinoma in Black

South Africans. Head Neck Pathol. 2013 Dec; 7(4): 361–72

• Wits University

• 55 OPSC

• 49% p16+

HPV in surgically treated oropharyngeal cancer in Cape TownPekkari M, Fagan JJ et al (Unpublished)

• 70 consecutive patients with OPC SCC at Groote Schuur and Private Hospitals between 1997 and 2005

• HPV DNA from broad range of HPV types analysed by PCR

• 47% HPV+• 97% HPV-16

• 27% both HPV-16 and HPV-33

Epicenter Number of patients

Base of tongue 3

Tonsil 46

Tonsillolingual sulcus 18

Soft palate 3

Africa

HPV-related OPC less common

Paradigm shifts

• Classic treatment

– Open surgery +/- Adjuvant RT

– Free tissue transfer flaps: Palate and mandible

• CRT: Excellent prognosis if HPV+

• Surgery / CRT

– Equivalent outcomes (unlike oral cavity)

– Excellent prognosis if HPV+

• HPV+ smokers: Worse outcomes

• HPV status

– Prognostic value

– Not to select treatment

Paradigm shifts

• Transoral resection

– CO2 laser

Paradigm shifts

• Transoral resection

– CO2 laser

– TORS

Paradigm shifts

• Clear resection margin?– Traditionally 5mm

– Transoral resection• 2mm?• Constrictor muscle?• Fascial dissection plane?

• Radiotherapy margins?

• De-intensifying CRT

• N+ neck– Up-front ND?

– Planned post-CRT ND?

– Post-CRT - PET restaging - Superselective ND?

Paradigm shiftsAJCC 8th Ed 2017

N0 No metastases

N1 Single / Multiple ipsilat <6cm

N2 Contralat / Bilat <6cm

N3 >6cm

N0 No metastases

N1 Single ipsilat <3cm, ENE –ve

N2a Single ipsilat >3cm, < 6cm, ENE –ve

N2b Multiple ipsilat, ENE -ve >6cm

N2c Contralat / bilat <6cm, ENE –ve

N3a >6cm, ENE -ve

N3b Any node, clinically ENE +ve

P16 Positive OPC P16 Negative OPC

N0 N1 N2

T0 NA I II

T1 I I II

T2 I I II

T3 II II III

T4 II II III

Any M1 is stage IV

N0 N1 N2a,b,c N3a,b

T1 I III IVA IVB

T2 II III IVA IVB

T3 III III IVA IVB

T4a IVA IVA IVA IVB

T4b IVB IVB IVB IVB

Any M1 is stage IVC

P16 Negative OPCP16 Positive OPC

N0 N1 N2

T0 NA I II

T1 I I II

T2 I I II

T3 II II III

T4 II II III

Any M1 is stage IV

N0 N1 N2a,b,c N3a,b

T1 I III IVA IVB

T2 II III IVA IVB

T3 III III IVA IVB

T4a IVA IVA IVA IVB

T4b IVB IVB IVB IVB

Any M1 is stage IVC

N0 N1 N2

T0 NA I II

T1 I I II

T2 I I II

T3 II II III

T4 II II III

Any M1 is stage IV

N0 N1 N2a,b,c N3a,b

T1 I III IVA IVB

T2 II III IVA IVB

T3 III III IVA IVB

T4a IVA IVA IVA IVB

T4b IVB IVB IVB IVB

Any M1 is stage IVC

N0 N1 N2

T0 NA I II

T1 I I II

T2 I I II

T3 II II III

T4 II II III

Any M1 is stage IV

N0 N1 N2a,b,c N3a,b

T1 I III IVA IVB

T2 II III IVA IVB

T3 III III IVA IVB

T4a IVA IVA IVA IVB

T4b IVB IVB IVB IVB

Any M1 is stage IVC

N0 N1 N2

T0 NA I II

T1 I I II

T2 I I II

T3 II II III

T4 II II III

Any M1 is stage IV

N0 N1 N2a,b,c N3a,b

T1 I III IVA IVB

T2 II III IVA IVB

T3 III III IVA IVB

T4a IVA IVA IVA IVB

T4b IVB IVB IVB IVB

Any M1 is stage IVC

Optimal therapeutic approach not easily defined

• No valid comparative studies of therapeutic options

• No single therapeutic regimen offers clear-cut, superior-survival advantage

• Therapeutic choice depends on

• Careful review of each case

• Staging

• General physical condition

http://www.cancer.gov/cancertopics/pdq/treatment/oropharyngeal/HealthProfessional

https://www.cancer.gov/types/head-and-neck/hp/adult/oropharyngeal-treatment-pdq#section/_49

• Emotional status

• Experience of treating team

• Available treatment facilities

National Cancer Institute 2018

Developing World Radiotherapy

• Africa: 29/52 countries have no radiation

• South America: 16/18 countries: major

restriction to access

• Developing countries

– Old technology

– Mainly palliative

Developing World CRT

• Expensive

• Toxic

• Complications

– Renal

– Hearing

– Dysphagia

– ORN

• Complex surveillance

• Difficult salvage surgery

Surgery

Transoral Approaches

• Tonsillectomy

• Partial glossectomy

• Transoral CO2 laser resection

• Transoral robotic surgery (TORS)

Open Approaches

• Mandibulotomy

Open Approaches

• Mandibulotomy

• Mandibulectomy

Open Approaches

• Mandibulotomy

• Mandibulectomy

Open Approaches

• Mandibulotomy

• Mandibulectomy

Open Approaches

• Mandibulotomy

• Mandibulectomy

Open Approaches

• Mandibulotomy

• Mandibulectomy

• Suprahyoid

Surgery: Patient selection

• Resectable?• Nasopharynx• Parapharyngeal space• Internal carotid artery• Infratemporal fossa• Extension along V3 to trigeminal ganglion

• Acceptable morbidity?• Soft palate• BOT

• Patient factors

• Package of care• Imaging: Planning and surveillance• Quality of (C)RT• Support: ICU, Nutrition, Swallowing, dental etc• Salvage surgery

What treatment for OPC?

Its Complicated!

Surgery in Oropharyngeal Cancer When is it appropriate?€¦ · Johan Fagan Division of...

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