Should Surgery Be First-Line Treatment for Head and Neck Cancer?

Surgery provides prognostic information, such as histologic aggression and lymph node involvement, that can guide the decision about adjuvant radiation or CRT.

For patients with mouth and throat cancer, many surgeons use the daVinci Surgical System to see if outcomes improve. (daVinci is FDA-approved for surgery on the torso, but not for head and neck procedures.)

Use of the robot reduces trauma, allows for complete tumor removal, and preserves voice and swallowing function. Moreover, the robotic arms are introduced through the mouth, thus obviating the need for incision. It has other advantages as well:

• Operative time is shorter.
• Its three arms (cameras and fiberoptic light) provide an advantage over a two-armed human.
• The robot’s command center contains a three-dimensional computer monitor, thus providing a real but magnified view of the surgical field.
• The double telescopic endoscope allows a closer view of the surgical site than one could get with unaided vision.
• Unlike other endoscopic systems, it does not require counterintuitive motions by the surgeon. It translates natural hand movements into the robot’s corresponding micro-movements. Thus, there is less chance for error.
• The robot’s computer eliminates even the smallest hand tremors.

Surgery for Larger Tumors

Dr. Haughey talked about the efficacy of surgery for larger tumors (T3 and T4) of the oral cavity, oropharynx, larynx, and hypopharynx. Ever since a 1991 study of surgery versus CRT, in which the results were equivocal, unfortunately there have been no further trials comparing the two treatment modalities.

Rather, pharmaceutical companies began sponsoring study after study of various oncologic drug cocktails-with and without concurrent radiation. Because there was so much money at stake and because some physicians leapt, lemming-like, over this ‘cliff’ of CRT, surgical treatment was largely ignored in clinical trials as well as the practice patterns of many cancer centers. But slowly, first in Europe and then in this country, with growing enthusiasm and success, surgeons began procedures on larger tumors of the upper aerodigestive tract with minimally invasive approaches.

Laser microsurgery has been a major part of that effort. Although laser endoscopy was developed in the 1970s, only in the last decade have these cost-effective techniques been used for larger tumors, Dr. Haughey said.

He went on to say that transoral laser microsurgery (TLM) can be used even in stage 3 and 4 disease of the larynx and hypopharynx (where the robot cannot yet be used) with excellent oncologic outcome, minimal hospital stay, and low morbidity. Moreover, TLM patients do not usually require a tracheostomy (in open surgery, about 80% of patients do). It is not a simple procedure, however. It requires the right equipment, well trained staff, and pathologists familiar with head and neck anatomy.