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.
Explore This IssueJune 2022
Her 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.
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.
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. “
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.
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.
HPV Vaccination Rates
Although it’s clear that children should be vaccinated for HPV, the rate for this vaccination is only 60% to 65%, compared to 90% for chicken pox vaccination, Dr. Cognetti said. Part of the reason is that parents don’t consider their kids at risk for sexually transmitted infections, he said.
The panelists tended to agree that it’s worth discussing HPV as a possible cause of oropharyngeal cancer symptoms—even if that prompts uncomfortable questions. Those awkward discussions are relatively uncommon, the panel physicians agreed.
Dr. Cognetti related a story about a patient who said she had seen multiple doctors about her ear pain and an inability to open her mouth normally. She was diagnosed with oropharyngeal cancer. “She was shocked to find out that [her symptoms were] related to HPV, because it was a topic that wasn’t discussed or disclosed at the time. That left a lasting impression on me from a medical standpoint that we educate our patients on this topic.”
Thomas R. Collins is a freelance medical writer based in Florida.