Previous. Conventional open surgery
Instead of engaging in discussions, it is preferable to focus on implementing minimal approach surgery. Let us review the facts.
The patient underwent a single stage transoral robotic (TORS) Radical Tonsillectomy (lateral oropharyngectomy) along with left neck dissection.
The da Vinci Robotic Surgery Xi system was used and optimal transoral exposure was achieved using the FKWO pharyngolaryngoscope. The surgery involved a standard and systematic TORS radical tonsillectomy which was completed in under an hour. No reconstructive procedure was necessary. The parapharyngeal fat pad was dissected from the deep side of the pharyngeal constrictor muscle, which was evidently included in the resection, but the carotids were not exposed. The pathological report confirmed free margins.
In the neck dissection a single metastatic node was identified. Macroscopic surgical dissection showed a clear dissection plane with the esternocleidomastoid muscle, internal jugular vein and eleventh cranial nerve. Hence, a conventional functional neck dissection involving levels Ib through IV was performed.
Tracheostomy was not required, and the patient was successfully extubated after surgery. No feeding tube was used and the patient initiated oral diet the second day. The postoperative period was uneventful. After receiving minimal dietary counselling, the patient was discharged from the hospital on the fourth day after surgery.
Based on the pathology report, the patient was diagnosed with pT3pN1 (stage II) HPV+ oropharyngeal carcinoma.
The patient was presented again at the Head&Neck cancer multidisciplinary committee, which had previously agreed in the surgical treatment. In accordance with the current guidelines (NCCN v. 2.2023) adjuvant treatment is recommended due to adverse pathologic features (pT3, vascular invasion, metastatic node>3cm). The oncologist supported this recommendation, while surgeons disagreed based on the aforementioned discussion. It should be noted that the guideline acknowledges that “the definition of an adverse pathologic feature in the context of HPV+ disease is an area of active research”. After thoroughly informing the patient and considering the published data and our more than ten years of experience with TORS for HPV+ oropharyngeal tumours, we advised against receiving adjuvant radiation therapy. The patient decided to be “TORS alone”.
An excellent prognosis is anticipated, with no treatment-related sequelae except for a scar in the neck. Speech and swallow functions are normal. Compare this outcome with that of any alternative treatment schedule.
Diagnosed with an oropharyngeal cancer? Ask for Minimal Approach Surgery.
J Granell, June 2023