I was dreading this day because I thought I was going to end up with a positive margin, but it worked out okay,” he said. Generally, he acknowledged, a tumor of this size and nature wasn’t something he would operate on. “I only tried it because the patient was so interested in surgery,” he said.
Explore This IssueJune 2022
Failure and Decision-Making
Dr. Khariwala noted that a main goal in managing these patients is to avoid performing chemoradiation and surgery on a patient, although sometimes that’s easier said than done.
“I think it’s really incumbent on us to determine which patients will benefit from a surgical approach rather than ‘shooting first and asking questions later,’ and then the patient ends up with three modalities,” he said. “The goal is to avoid that whenever possible. It isn’t always possible. When patients are upstaged and they end up needing chemotherapy and radiation on pathology, I kind of see that as a failure,” with potential long-term functional consequences for the patient, Dr. Khariwala said.
Dr. Cognetti said that he sees it differently. “I wouldn’t consider somebody getting chemoradiotherapy afterward as a failure,” he said. “It isn’t ideal, but I think a failure is somebody who fails oncologically or fails functionally. And if you set your target as always avoiding chemoradiation, then you’re probably not going to operate on patients who would benefit from it because you’re pulling up a little too early.”
Decision-making on HPV-positive oropharyngeal cancer patients should be done based on both the primary and the neck disease, Dr. Khariwala said. “Both the nature and extent of the primary tumor and the neck disease should first be considered separately—are there contraindications to surgery in either of those sites?” he said. “Then, look at them together—what does this mean for the overall care of the patient?”
Dr. Zender said that an ongoing problem in the field is determining how far a tumor extends. “We know we still struggle with predicting ECE [extracapsular extension],” he said.
“When it’s obvious, we can all tell, but when it’s small amounts—1 or 2 millimeters—it’s really challenging, especially on imaging,” Dr. Khariwala said. “The consensus of the literature is that we don’t have a good, reliable way of figuring this out preoperatively.”
Transoral robotic surgery has meant less morbidity and fewer functional deficits, enhancing its appeal. But as its use has increased, so have challenges such as positive surgical margins. “I think it’s important to push the envelope, but we also have to have alignment with our medical and radiation oncology colleagues,” said Dr. Khariwala.