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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
Oropharynx
• Breathing
• Swallowing
• Speech
• Nasopharyngeal competence
OPSC
• 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HPV in surgically treated oropharyngeal cancer in Cape TownPekkari M, Fagan JJ et al (Unpublished)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
Paradigm shiftsAJCC 8th Ed 2017
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
Paradigm shiftsAJCC 8th Ed 2017
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
Paradigm shiftsAJCC 8th Ed 2017
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
Paradigm shiftsAJCC 8th Ed 2017
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
Paradigm shiftsAJCC 8th Ed 2017
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
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
Transoral Approaches
• Partial glossectomy
Transoral Approaches
• Transoral CO2 laser resection
Transoral Approaches
• 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!
