SURGERY VS RADIOTHERAPY IN EARLY OPX TUMOR

1. Surgery Versus Radiotherapy -
Oropharyngeal Tumors: Is the issue settled ?
Presenter:Dr Abhijeet singh
Dr Abhinav Thaduri
Moderator:Dr Dharmaram Poonia
AIIMS

2. Incidence

6. • Substantial Western literature on the prevalence of
HPV in oropharyngeal SCC reported to be between 28%
to 68%.
• Hammarstedt L, Lindquist D, Dahlstrand H, Romanitan M, Dahlgren LO, Joneberg J, et al. Human
papillomavirus as a risk factor for the increase in incidence of tonsillar cancer. Int J
Cancer. 2006;119:2620–
• D’Souza G, Kreimer AR, Viscidi R, Pawlita M, Fakhry C, Koch WM, et al. Case-control study of human
papillomavirus and oropharyngeal cancer. N Engl J Med. 2007;356:1944–56.
• Hafkamp HC, Manni JJ, Haesevoets A, Voogd AC, Schepers M, Bot FJ, et al. Marked differences in
survival rate between smokers and nonsmokers with HPV 16-associated tonsillar carcinomas. Int J
Cancer. 2008;122:2656–64

8. Indian scenario

9. Guidelines
Index
Head
and
Neck
Cancers
TOC
Staging,
MS,
References
Practice
Guidelines
in
Oncology
–
v.2.2008
NCCN
®
Base
of
tongue/tonsil/posterior
pharyngeal
wall/soft
palate
CLINICAL
STAGING
T1-2,
N0-1
Any
T,
N2-3
T3-4a,
N+
T3-4a,
N0
WORKUP
·
·
·
·
·
·
·
·
H&P
Biopsy
HPV
testing
suggested
Chest
imaging
CT
with
contrast
or
MRI
recommended
for
primary
and
neck
Dental
evaluation,
including
panorex
as
indicated
Speech
&
swallowing
evaluation
as
indicated
Examination
under
anesthesia
with
endoscopy
Preanesthesia
studies
·
Multidisciplinary
consultation
as
indicated
See
Treatment
of
Primary
and
Neck
(ORPH-2)
See
Treatment
of
Primary
and
Neck
(ORPH-3)
See
Treatment
of
Primary
and
Neck
(ORPH-4)
Unresectable
See
Treatment
of
Head
and
Neck
Cancer
(ADV-1)
Cancer
of
the
Oropharynx
Head
and
Neck
Cancers

13. Evolution of treatment in H&N cancers
Trial conclusion
Veterans Affairs Laryngeal Cancer Study
Group
definitive radiation therapy can be
effective in preserving the larynx in a high
percentage of patients, without
compromising overall survival
The larynx was preserved in 64 percent of
the patients
Intergroup Radiation Therapy Oncology
Group 91-11 study
Locoregional control and larynx
preservation were significantly improved
with concomitant cisplatin/RT compared
with the induction arm or RT alone

14. Final Results of the 94-01 French Head
and Neck
Oncology and Radiotherapy Group
Concomitant radiochemotherapy
improved overall survival and
locoregional control rates
Parsons et al
Squamous Cell Carcinoma of the
Oropharynx
Surgery, Radiation Therapy, or Both
Local control, local-regional control,
5-year survival, were
similar for patients who underwent S
+ RT or RT ND
Rates of severe or fatal complications
were significantly greater for the S
RT group

15. Two distinct types of patients with OPSCC
• The older
• human
papillomavirus(HPV)–
negative patient
• Large primary cancer and
history of tobacco and
alcohol abuse
• High risk of second
primary cancers from field
cancerization.
• The younger
• HPV-positive patient
• nonsmoker and nondrinker
• with a small primary
• sometimes undetectable
primary, large cervical
nodes
• Dramatically improved
longterm survival.
Deschler DG, Richmon JD, Khariwala SS, et al. The “new” head and neck
cancer patient-young, nonsmoker, nondrinker, and HPV positive: evaluation.
Otolaryngol Head Neck Surg. 2014; 151:375–380

17. Ideal treatment option
• Pathological staging – prognostication , may
permit treatment de-
intensification/intensification in some patients
• Determine need for adjuvant treatment.
• Good Oncological outcome.
• Good long term functional outcomes in terms
of QOL.

18. Why there is need for tailoring the treatment
options in OPSCC
Why there is renewed interest in upfront surgery
to treat OPSCC?

23. Trans oral laser surgery

24. TORS

29. Surgery vs RT QOL
• Fundamentally, no single measure of swallowing
is universally accepted or considered globally
effective to completely define dysphagia.
• VFSS is often termed the ‘gold standard measure
of swallowing
• The MDADI was the most commonly cited patient
reported measure in this review, allowing for a
comparison between treatments.

33. INTRODUCTION
• 30% of patients with c T1–T2 N0 disease will
present occult nodal disease
• 50% of patients with advanced-stage OPSCC
will develop nodal metastasis
• 60% of patients with advanced-stage tumors
still develop recurrent disease
*Golusin ́ ki nd Golusin ́ ska-Kardach E (2019) Current Role of Surgery in the
Management of Oropharyngeal Cancer. Front. Oncol. 9:388. doi: 10.3389/fonc.2019.0038

47. Predictors of swallowing function
Predictors of swallowing function included baseline func-
tion, T-stage, nodal status, base of tongue primary tumors,
reported tracheostomy rates in excess of 20 %, presum-
ably in cases with advanced-stage tumors, but this strati-
fication was not specified [11, 13, 16]. Among all papers
(pooled n = 411 cases reporting tracheostomy rates), only
two patients were permanently tracheostomy dependent
[14, 16]. When reported, mean tracheostomy dependence
ranged from 7 to 8 days [11, 14].
Speech
Speech-related outcomes were described in 5 series [11, 13,
15, 19, 29]. Summary speech ratings were taken longitudi-
nally in 3 studies, according to the clinician-rated PSS-HN
Understandability of Speech scale [30] in 2 series [13, 19]
and using an ordinal, nonvalidated speech grade (normal,
minor, gross) in the remaining [11]. The former reported
PSS-HN speech scores above 75 (indicating “understand-
able most of the time” or better) at all post-TORS intervals,
and speech received “normal” ratings on the initial post-
TORS rating in the latter series. Transient hypernasality
was reported in 3–9 % of patients in 3 studies [11, 15, 29].
Long-term function after TORS
Long-term gastrostomy tube rates were reported in 426
patients from 11 studies and ranged from 0 to 7 %, with mean
follow-up in most studies between 1 and 2 years (Table 1).
Long-term outcomes data from instrumental swallowing stud-
ies were not quantified in any of the 12 studies. Longitudinal
studies only quantified functional outcomes with standard-
Fig. 2 Crude rates of gastrostomy utilization after primary TORS
(± adjuvant therapy) compared with definitive IMRT (± systemic ther-
apy). Excluding studies that restricted inclusion to early-stage disease
and those that prophylactically placed PEG tubes in all patients, 18–
39 % (median 23 %) required gastrostomy tubes in TORS series com-
pared with 29–60 % (median 46 %) of patients in definitive IMRT
series
Table 2 Time to oral intake after TORS for OPC
* No. of studies reporting time to oral intake by T-stage
T-stage No. of
studies*
Time to oral intake after TORS
Time interval % patients oral
T1-T2 1 POD1 96 [12]
T1-T3 2 By discharge 100 [17]
By week 1 100 [13]
T1-T4 3 POD1 51 [11]
By discharge 69 [26]
73 [18]
By week 2 83 [26]
By week 4 89 [11]
• Composite MD Anderson Dysphagia Inventory (MDADI) scores
ranged from 65.2 to 78
• Incidence of postoperative pneumonia was 0–7 %

57. FUTURE DIRECTION

58. Ref: Golusin ́ ski and Golusin ́ ska-Kardach E (2019) Current Role of Surgery in the Management of Oropharyngeal Cancer.
Front. Oncol. 9:388. doi: 10.3389/fonc.2019.00388
CONTRAINDICATION TO TOS

59. CONCLUSION
• Upfront surgery has the potential to stratify
patients as per pathological risks over CTRT
• Potential to tailor (De-escalation/escalation)
adjuvant treatment.
• Shorter treatment duration /cost effectiveness
• Preventing long term toxicities associated with
CTRT.
• Chance of preventing RT induced second primary.
• Improved QOL with single modality treatment
(surgery) in selected individuals.

60. TAKE HOME
• TORS may achieve acceptable oncologic
outcomes and better functional outcomes
than traditional open surgical
approaches/definitive chemoradiotherapy.

61. A NEVER ENDING DEBATE!
THANK YOU