The patient undergoes surgery: transoral partial pharyngectomy and right selective neck dissection – levels I–IV (see Figure 11.3).
Question: Based on the pathological findings, what additional treatment would you recommend?
Answer: Close observation. In general, margins greater than 5 mm are considered ideal. However, in the tonsillar fossa it may be hard to achieve greater than 5 mm. This patient now has a history of two head and neck cancers and mucosal dysplasia associated with a second primary. She should have close clinical follow‐up.
FIGURE 11.3 This intraoperative photo shows the resection bed following a robotic right‐sided radical tonsillectomy. Pathology reveals no tumor identified in 25 lymph nodes (0/25). The primary tumor is a 1.2 cm well‐ to moderately differentiated SCC. All margins free of cancer by at least 5 mm. Reconstruction of intraoral soft palate defect is performed with a pedicled buccal fat flap.
Key Points
SCC of the oropharynx is still often associated with tobacco and alcohol use.
Treatment for HPV negative cancer follows the same general principles as treatment for HPV positive cancer. The goal is to achieve cure with the fewest modalities of treatment possible.
Extent of neck dissection is dictated by the size of the tumor and the exact location within the pharynx. For cN0 patients, ipsilateral selective neck dissection is considered adequate.
Surgical treatment alone of HPV negative cancer is limited to those patients with early‐stage primary tumor and no more than one involved lymph node at the time of evaluation and no pathologic features such as lymphovascular invasion and perineural invasion.
Multiple Choice Questions
1 You are evaluating a 52‐year‐old male patient with a 3 cm left neck lymph node where an ultrasound guided fine needle aspiration confirms p16+ SCC. Your office exam, including fiberoptic laryngoscopy, as well as a PET/CT fails to yield an identifiable primary tumor. What would be the most appropriate step in the management of this patient?A left‐sided selective neck dissection followed by close observation.A left‐sided selective neck dissection followed by radiation therapy to the neck and oropharynx.A left‐sided selective neck dissection with direct laryngoscopy. If no primary tumor is seen, palatine and lingual tonsillectomies should be performed.Definitive chemoradiation therapy.Answer: c. In this patient with left neck cancer, unknown primary, the fact that the neck node is p16+ suggests a likely oropharyngeal primary site. While both nonsurgical and surgical treatment options should be discussed with the patient in all instances, additional evaluation for potential primary sites is indicated. With the increased visualization offered by transoral robotic surgical systems, both lingual and palatine tonsillectomies should be performed as these sites are the most common locations to find occult primary tumors. Choice b is a reasonable option, but ideally, attempts would be made to find the primary tumor to focus any radiotherapy.
2 Which of these patients is NOT suitable for transoral resection of the primary neoplasm?A patient with T1 primary neoplasm located in the palatine tonsil and inter‐incisor opening of 2 cm.Edentulous patient, excellent neck extension, T4 primary neoplasm located in the palatine tonsil.Patient with T1 primary neoplasm located in the palatine tonsil with medially located (retropharyngeal) internal carotid artery.a and c.All of the above.Answer: e. Patients being considered for transoral resection of primary oropharyngeal neoplasm require careful selection. Factors that should be considered include availability of physician and institutional experience in transoral surgery, extent of disease and anatomical factors among other considerations. Anatomical factors that may be considered as absolute contraindications include trismus, large primary tumor (including most T3 and all T4 tumors), inability to obtain adequate exposure due to limitations of neck extension, trismus, presence of mandibular tori, or sequelae of prior therapy. Other factors that may suggest relative contraindications for transoral resection include direct extension of primary neoplasm across the midline of the base of tongue, extension beyond the midline of the soft palate or the posterior pharyngeal wall, or extension out to involved level II nodes and/or major vessel encasement. Patients with medialized retropharyngeal carotid arteries may experience vascular exposure with resection of the primary site and may present a relative contraindication especially when expertise for advanced reconstruction including free tissue transfer is unavailable. The ideal candidate for transoral resection is an edentulous patient with well‐lateralized, small (T1 or T2) primary, with no trismus and good neck extension. When the candidacy for transoral resection is ambiguous, clinicians may consider performing an exam under anesthesia before determining care plans.
3 Which of the following is a potential side effect of the chemotherapy agent cisplatin?Sensorineural hearing loss.Polyneuronal distal neuropathy.Renal insufficiency.All of the above.Answer: d. These are well‐known complications of this agent.
4 When should one consider taxane‐based chemotherapy as an alternative to platinum‐based regimens?Always, as taxane‐based regimens have superior efficacy, albeit with greater toxicity.Never, as taxane‐based regimens have inferior oncologic efficacy when compared to radiation alone.Only considered when there is a contraindication to platinum.As a first‐line therapy for patients with unresectable locoregionally recurrent and/or distant metastatic disease.Answer: c. Carboplatin plus paclitaxel is generally inferior to platinum‐based chemotherapy. However, studies have demonstrated favorable locoregional control and short‐term survival rates; therefore, this could be considered in platinum‐ineligible patients such as those with compromised baseline renal function. Immunotherapy (not taxane‐based chemotherapy) is considered first‐line therapy for unresectable locoregionally recurrent and/or distant metastatic disease.
5 What is the current standard of care for post treatment restaging following nonoperative management of oropharyngeal cancer?8‐week post‐treatment PET/CT.12‐week post‐treatment PET/CT. 16‐week post‐treatment PET/CT.Planned salvage neck dissection.Answer: b. Mehanna et al. (2016) performed a prospective study of 564 patients and evaluated a 12‐week PET/CT scan as compared with a planned neck dissection to understand the role of image‐guided surveillance post‐treatment. While there was no significant survival difference in the two groups, the group managed by PET/CT surveillance had noticeably fewer operations, and the strategy was more cost‐effective. Obtaining a PET/CT prior to 12 weeks runs the risk of false positive results, while delaying imaging may allow for disease progression.
6 When might one consider induction chemotherapy?Desire for rapid initiation of therapy.Rapid disease progression in a healthy patient who can tolerate the potential toxicity.Potential oligometastatic disease that is not amenable to biopsy.All of the above.Answer: d. While there is no survival benefit to adding induction chemotherapy prior to definitive concurrent chemoradiation, it represents a noninferior approach compared with concurrent chemoradiation alone. Often it is an option to start therapy immediately, particularly when a patient cannot wait 2 weeks for radiation planning. It has been useful in the setting of low (level III/IV) cervical nodal involvement where the risk of distant metastatic spread is high, and in oligometastatic disease that is not amenable to biopsy where one wants to use chemotherapy to select patients that may respond to treatment. Chemoselection has been best studied in SCC of the larynx, where it has been shown to be an effective strategy.
7 What role does immunotherapy
