A 78-year-old woman came to see Samir S. Khariwala, MD, MS, chair of otolaryngology–head and neck surgery at the University of Minnesota, Twin Cities, in Saint Paul and Minneapolis, about an HPV-positive tumor of the oropharynx. The woman was fairly frail, Dr. Khariwala said, and she was advised by another facility to pursue chemoradiation therapy. But the patient had a strong desire for surgery.
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June 2022Her primary disease was very bulky, but there was no sign of neck disease. Dr. Khariwala had to decide: Should he go ahead with the surgery, given the possibility of a positive margin or perioperative complication in a frail patient?
This difficult scenario was one of the discussion points in a session at the 2022 Triological Society Combined Sections Meeting, during which expert physician panelists discussed the rise in HPV oropharyngeal cancer, the sometimes vexing management decisions, and the role of HPV vaccines.
Surgery Decisions
Sound management of HPV oropharyngeal cancer is vital because of the rapid increase in its prevalence, said Chad A. Zender, MD, a professor of otolaryngology and the associate chief medical officer at the University of Cincinnati in Ohio. HPV accounted for 15% of oropharyngeal cancers in 1980. By the year 2010, that figure had risen to 85%. “Nonetheless, most patients who are exposed to HPV don’t develop oropharyngeal cancer, and clearly work needs to be done to identify those at risk,” Dr. Zender said.
David M. Cognetti, MD, chair of otolaryngology–head and neck surgery at Jefferson University Hospitals in Philadelphia, offered a caveat on a surgical approach in the case of the 78-year-old patient: Don’t become overconfident due to the lack of neck disease.
“No neck disease is nice and tempting, and it lowers the patient’s stage, if you will,” he said. “But I think for oropharyngeal tumors, when you’re looking at a surgical decision, it’s always driven by the primary. The T stage is what drives the patient’s prognosis, and the primary is what drives their functional outcome. I often find myself making the decision on surgical appropriateness based on the primary.”
Dr. Zender added that, considering the bulk of the tumor, he “wouldn’t be surprised” if the patient was experiencing trismus and the tumor was somewhat fixed.
For oropharyngeal tumors, when you’re looking at a surgical decision, it’s always driven by the primary. —David M. Cognetti, MD
Dr. Khariwala said he was indeed reluctant to pursue surgery. But when he took the patient into the operating room for a thorough exam, the tumor wasn’t fixed, and the patient didn’t have trismus. The tumor bulk seen on imaging was almost entirely exophytic, which limited the invasion of the surrounding tissue. Based on this, he went ahead with surgery. “