Traditional open surgical approaches are indicated for treatment of select tumor subsites of head and neck cancer, but can also result in major cosmetic and functional morbidity. Transoral surgical approaches have been used for head and neck cancer since the 1960s, with their application continuing to evolve with the changing landscape of this disease and recent innovations in surgical instrumentation. The potential to further reduce treatment morbidity with transoral surgery, while optimizing oncologic outcomes, continues to be investigated. This review examines current literature evaluating oncologic and quality-of-life outcomes achieved through transoral head and neck surgery.
Key points
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Quality of life in patients with head and neck cancer can be largely affected by posttreatment preservation of laryngeal function.
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Comprehensive radiation therapy usually creates a significant swallowing dysfunction that may be potentiated by chemotherapy.
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Transoral endoscopic head and neck surgeries with or without adjuvant therapy show survival rates comparable with those of nonsurgical organ-preservation therapy in head and neck cancer, and may result in less swallow impairment for select patients.
Background and introduction
The Multidisciplinary Care of Head and Neck Cancer
Head and neck cancer (HNC) is a significant public health problem worldwide, with more than 500,000 new cases per year. India, the United States, and western Europe have the highest incidences of HNC worldwide with age-standardized incidence rates of 10.5 to 14.1 per 100,000 persons in 2012. Tobacco use and alcohol consumption are major causes of HNC, showing a multiplicative effect on cancer risk when used together. In the last 2 decades, human papillomavirus (HPV) has been identified as an important risk factor for developing HNC. Chaturvedi and colleagues described the striking new association between oropharyngeal cancer (OPC) and high-risk strains of HPV, elucidating a new epidemiology in a subset of HNC patients. This study estimated population-based incidence of HPV-positive and HPV-negative OPC in the United States using the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2004. During this period, HPV-positive OPC increased by 225% (95% confidence interval [CI] 208%–242%; from 0.8 per 100,000 to 2.6 per 100,000), whereas the incidence of HPV-negative cancers declined by 50% (95% CI 47%–53%; from 2.0 per 100,000 to 1.0 per 100,000). Patients with HPV-associated OPC are more likely to be nonsmokers, male, and younger than “traditional” patients with HNC ( Table 1 ).
| HPV-Positive | HPV-Negative | |
|---|---|---|
| Incidence | Increasing | Decreasing |
| Age | Younger | Older |
| Gender | 3:1 (M/F) | 3:1 (M/F) |
| Risk factors | Sexual behavior | Tobacco, alcohol |
| Cofactors | Marijuana, immunosuppression | Diet, oral hygiene |
| Molecular genetics | p16 ↑ | p16 ↓ |
| Rb ↓ | Rb ↑ | |
| p53 wild-type | p53 mutated | |
| Anatomic site | Lingual and palatine tonsils | All sites |
| Pathologic findings | ||
| Primary | Basaloid | Keratinized |
| Lymphatic metastasis | Cystic, mixed | Solid |
| Survival | Better | Worse |
In the past, OPCs were often treated with disfiguring transfacial, transmandibular approaches, yet many patients still required extensive adjuvant therapy postoperatively. Poor posttreatment function led multidisciplinary teams worldwide to explore alternative options, such as concurrent chemotherapy with radiation therapy (CCRT).
The Radiation Therapy Oncology Group (RTOG) trial 0129 provided strong evidence that HPV status is an independent prognostic factor for overall survival (OS) and progression-free survival (PFS) among patients with OPC. Furthermore, HPV-positive tumors were exquisitely responsive to CCRT. Locoregional failure at 3 years was 21% lower in patients with HPV-positive tumors, at 13.6% (95% CI 8.9%–18.3%) versus 35.1% (95% CI 26.4–43.8) for HPV-negative tumors ( P <.001). The 3-year OS for HPV-positive patients treated with CCRT was 83%, including T3-T4 patients and those with advanced staged regional disease.
The treatment of advanced-stage laryngeal and hypopharyngeal cancers historically required radical surgery, most often a total laryngectomy with partial or total pharyngectomy, followed by adjuvant radiation therapy. Although radical surgery can achieve oncologic control, the functional sacrifices to voice, swallowing, and cosmesis can be devastating for patients. In 1991 the Veterans Affairs Laryngeal Cancer Study Group (VALCSG) reported the first randomized comparison between laryngectomy with or without radiation therapy, and induction chemotherapy followed by radiation therapy for the treatment of advanced laryngeal cancer. This study demonstrated the role of induction chemotherapy (cisplatin and 5-fluorouracil) followed by radiation therapy in laryngeal preservation. Equivalent survival rates were achieved in the surgical and nonsurgical treatment arms. Of the patients receiving induction chemotherapy, 64% ultimately preserved their larynges, a major development in functional preservation that led to widespread adoption of nonsurgical treatment protocols. Subsequent important randomized trials demonstrated a significant potential for laryngeal preservation in the nonsurgical treatment of laryngeal and hypopharyngeal cancers.
Despite enthusiasm for CCRT and induction chemotherapy protocols, significant delayed toxicity and functional morbidity can still result, even with anatomic larynx preservation. Dysphagia related to chronic xerostomia and impaired laryngeal function may be the most debilitating of functional impairments in HNC survivors. In a pooled analysis of 3 RTOG trials of concomitant chemoradiotherapy, late onset of RTOG grade 3 and 4 laryngeal toxicity was reported in 35% of 101 OPC survivors. The 3-year prevalence of dysphagia approaches 50% in population-level data from OPC survivors in the SEER-Medicare database. As the landscape of HNC continues to evolve, in particular with the growing incidence of HPV-associated OPC patients achieving long-term survival, a renewed interest in the role of surgery as a function-preserving treatment is being investigated.
Background and introduction
The Multidisciplinary Care of Head and Neck Cancer
Head and neck cancer (HNC) is a significant public health problem worldwide, with more than 500,000 new cases per year. India, the United States, and western Europe have the highest incidences of HNC worldwide with age-standardized incidence rates of 10.5 to 14.1 per 100,000 persons in 2012. Tobacco use and alcohol consumption are major causes of HNC, showing a multiplicative effect on cancer risk when used together. In the last 2 decades, human papillomavirus (HPV) has been identified as an important risk factor for developing HNC. Chaturvedi and colleagues described the striking new association between oropharyngeal cancer (OPC) and high-risk strains of HPV, elucidating a new epidemiology in a subset of HNC patients. This study estimated population-based incidence of HPV-positive and HPV-negative OPC in the United States using the Surveillance, Epidemiology, and End Results (SEER) database from 1988 to 2004. During this period, HPV-positive OPC increased by 225% (95% confidence interval [CI] 208%–242%; from 0.8 per 100,000 to 2.6 per 100,000), whereas the incidence of HPV-negative cancers declined by 50% (95% CI 47%–53%; from 2.0 per 100,000 to 1.0 per 100,000). Patients with HPV-associated OPC are more likely to be nonsmokers, male, and younger than “traditional” patients with HNC ( Table 1 ).
| HPV-Positive | HPV-Negative | |
|---|---|---|
| Incidence | Increasing | Decreasing |
| Age | Younger | Older |
| Gender | 3:1 (M/F) | 3:1 (M/F) |
| Risk factors | Sexual behavior | Tobacco, alcohol |
| Cofactors | Marijuana, immunosuppression | Diet, oral hygiene |
| Molecular genetics | p16 ↑ | p16 ↓ |
| Rb ↓ | Rb ↑ | |
| p53 wild-type | p53 mutated | |
| Anatomic site | Lingual and palatine tonsils | All sites |
| Pathologic findings | ||
| Primary | Basaloid | Keratinized |
| Lymphatic metastasis | Cystic, mixed | Solid |
| Survival | Better | Worse |
In the past, OPCs were often treated with disfiguring transfacial, transmandibular approaches, yet many patients still required extensive adjuvant therapy postoperatively. Poor posttreatment function led multidisciplinary teams worldwide to explore alternative options, such as concurrent chemotherapy with radiation therapy (CCRT).
The Radiation Therapy Oncology Group (RTOG) trial 0129 provided strong evidence that HPV status is an independent prognostic factor for overall survival (OS) and progression-free survival (PFS) among patients with OPC. Furthermore, HPV-positive tumors were exquisitely responsive to CCRT. Locoregional failure at 3 years was 21% lower in patients with HPV-positive tumors, at 13.6% (95% CI 8.9%–18.3%) versus 35.1% (95% CI 26.4–43.8) for HPV-negative tumors ( P <.001). The 3-year OS for HPV-positive patients treated with CCRT was 83%, including T3-T4 patients and those with advanced staged regional disease.
The treatment of advanced-stage laryngeal and hypopharyngeal cancers historically required radical surgery, most often a total laryngectomy with partial or total pharyngectomy, followed by adjuvant radiation therapy. Although radical surgery can achieve oncologic control, the functional sacrifices to voice, swallowing, and cosmesis can be devastating for patients. In 1991 the Veterans Affairs Laryngeal Cancer Study Group (VALCSG) reported the first randomized comparison between laryngectomy with or without radiation therapy, and induction chemotherapy followed by radiation therapy for the treatment of advanced laryngeal cancer. This study demonstrated the role of induction chemotherapy (cisplatin and 5-fluorouracil) followed by radiation therapy in laryngeal preservation. Equivalent survival rates were achieved in the surgical and nonsurgical treatment arms. Of the patients receiving induction chemotherapy, 64% ultimately preserved their larynges, a major development in functional preservation that led to widespread adoption of nonsurgical treatment protocols. Subsequent important randomized trials demonstrated a significant potential for laryngeal preservation in the nonsurgical treatment of laryngeal and hypopharyngeal cancers.
Despite enthusiasm for CCRT and induction chemotherapy protocols, significant delayed toxicity and functional morbidity can still result, even with anatomic larynx preservation. Dysphagia related to chronic xerostomia and impaired laryngeal function may be the most debilitating of functional impairments in HNC survivors. In a pooled analysis of 3 RTOG trials of concomitant chemoradiotherapy, late onset of RTOG grade 3 and 4 laryngeal toxicity was reported in 35% of 101 OPC survivors. The 3-year prevalence of dysphagia approaches 50% in population-level data from OPC survivors in the SEER-Medicare database. As the landscape of HNC continues to evolve, in particular with the growing incidence of HPV-associated OPC patients achieving long-term survival, a renewed interest in the role of surgery as a function-preserving treatment is being investigated.
Transoral endoscopic head and neck surgery
Transoral endoscopic head and neck surgery (eHNS) has emerged as a vital part of multidisciplinary HNC care. In comparison with open surgical approaches, eHNS minimizes the extent of soft-tissue dissection that may potentially disrupt organs of speech, voice, and swallowing. For this reason eHNS has received increasing attention for the primary treatment of select HNCs. When performed with elective neck dissection, the ability to obtain pathologic staging information by primary surgical treatment is an important advantage that may direct adjuvant therapy or negate its need. The ability to determine the presence or absence of perineural invasion (PNI) or lymphovascular invasion (LVI) at the primary site, in addition to the regional lymph node burden and presence of extracapsular extension, can dictate whether to intensify or de-intensify adjuvant therapy. Walvekar and colleagues reported a series of 49 patients with clinically early-stage OPC, treated with primary surgery. Clinical staging was modified in 20 of 49 (40%) patients after surgery, with 12 of these patients pathologically downstaged. The additional information provided by eHNS staging may allow select patients to minimize treatment morbidity when adjuvant therapy can be de-intensified or avoided.
The role of eHNS in HPV-positive OPC patients is currently being studied in the phase II randomized clinical trial ECOG 3311. This trial examines the role of transoral surgical resection in p16-positive oropharyngeal cancers, for the de-escalation of the overall treatment regimen. In particular, p16-positive, locally advanced (stage III/IV: cT1–2, N1-N2b, M0) OPC patients are eligible for participation. There are essentially 4 treatment arms:
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All patients undergo transoral surgical resection of the primary tumor, with a neck dissection of cervical levels II through IV.
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Treatment arm 1 (low risk: pT1–2, N0–1) patients are subsequently observed.
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Treatment arms 2 and 3 (intermediate risk: including clear but close margins; perineural or lymphovascular invasion; <1 mm of nodal extracapsular extension; or 2–4 metastatic lymph nodes)
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These patients are randomized to either arm 2: intensity-modulated radiation therapy (IMRT) of 50 Gy in 25 fractionated doses; or arm 3: IMRT of 60 Gy in 30 fractionated doses.
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Treatment arm 4 (high risk: positive margins; >1 mm of nodal extracapsular extension; or at least 5 metastatic lymph nodes)
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These patients receive IMRT of 66 Gy in 33 fractionated doses and cisplatin 40 mg/mm 2 weekly.
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This trial primarily aims to compare 2-year PFS in patients receiving low-dose adjuvant radiation (treatment arm 2) versus current standard adjuvant dosing at 60 Gy (treatment arm 3). Secondarily the trial will evaluate treatment toxicity, functional outcomes, and patients’ quality of life. Patients at intermediate risk for disease progression are the primary interest: in these patients full adjuvant dosing of radiation therapy may be reduced to lessen toxicity. Transoral surgery may play a role in determining which patients are at intermediate risk for disease progression, and whether de-escalation of therapy is oncologically feasible.
The 2 most commonly used eHNS techniques for HNC are transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). In contrast to open surgical approaches, TLM and TORS approach mucosal tumors via direct, magnified visualization. Whether using a binocular microscope and carbon dioxide laser for TLM or the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) for TORS, the successful resection of select laryngeal and pharyngeal tumors relies on both adequate visualization of the tumor and adequate exposure for surgical ablative instruments. There are several differences between these 2 eHNS techniques.
TLM is performed under direct suspension laryngoscopy (or in OPC, pharyngoscopy), using a binocular operating microscope, microsurgical instruments, and a carbon dioxide laser. TLM relies on the surgeon’s understanding of the 3-dimensional anatomy of the tumor’s extent and surrounding anatomy. Described first in the late 1960s and early 1970s, the technique of TLM has being progressively refined. Steiner first described division of the tumor as a means to understand the full depth and extent of the lesion, before systematically performing circumferential resection with appropriate surgical margins. TLM requires a direct line-of-sight approach to tumors, which was a limitation to its use in the treatment of tongue-base tumors. The development of curved and angled fiberoptic lasers has facilitated operations around the curvature of the tongue base. In tongue-base TLM, tumor resection may require piecemeal excision rather than en bloc excision. Although this may seem oncologically contentious, several studies have reported equivalent negative margins achieved during piecemeal and en bloc resection.
In 2009, the US Food and Drug Administration (FDA) approved the use of the da Vinci Surgical System for transoral surgical treatment of OPC and sleep apnea procedures. TORS for HNC is performed using a central endoscopic camera arm and 2 surgical arms. All 3 arms are controlled by a surgeon sitting at a remote console. After appropriate dental protection, an oral retractor is positioned within the mouth, and a 0° or 30° endoscopic camera is introduced into the oropharynx followed by 2 surgical arms carrying interchangeable 5-mm or 8-mm wide working instruments (eg, grasping forceps, electrocautery, CO 2 or thulium laser). The instruments have 540° of wristed range of motion. At the remote console, the surgeon views a 3-dimensional display of the surgical site, with finger-control handpieces directing movements of the robot’s instruments and camera. In tongue-base cancer surgery, the use of a 30° scope may offer improved visual exposure in comparison with the line-of-sight microscope views of TLM, and can facilitate en bloc tumor resection.
Numerous retrospective single-institution studies have examined the oncologic and functional outcomes of TLM and TORS in HNC treatment, in addition to 2 larger multicenter retrospective studies reporting outcomes comparable with those after radiation-based primary treatment protocols. As described earlier, important initiatives to prospectively study the role of eHNS techniques in multidisciplinary HNC care are under way. In many cases of primary HNC surgery, eHNS has replaced open surgical approaches with reduced acute morbidity, shorter hospital stay, and quicker functional recovery. Defining which HNC patients are appropriate candidates for eHNS is challenging; oncologic principles for resection margins must be achievable. Studies consistently report TLM and TORS achieving negative surgical margins at rates greater than 88%. The American Joint Committee on Cancer tumor staging system alone does not sufficiently identify which patients will benefit from eHNS. For example, a T1 midline tongue-base tumor may be small in absolute volume, but have a broad-based, sessile shape requiring extensive bilateral tongue-base resection to obtain negative margins. Conversely, a 4.5-cm T3 tonsillar primary may have a pedunculated, narrow-stalked shape, making negative margins attainable with less sacrifice of normal tissue. In the former scenario, primary radiation therapy may offer the least morbidity. In the latter, if transoral surgery can achieve negative margins and both PNI and LVI are absent, this situation may argue for dose reduction or deferral of adjuvant radiation.
Role of Endoscopic Head and Neck Surgery in Oropharyngeal Cancer
Traditional open surgical approaches to the oropharynx have included lateral or supraglottic pharyngotomy, and mandibular osteotomy and swing. Transoral access without specialized instrumentation is difficult for both tumor visualization and maneuverability of surgical instruments. Therefore the open approaches were the most accepted surgical techniques, despite requiring dissection through supporting oral cavity musculature and/or disrupting mandibular integrity. Complex reconstruction was often indicated after open surgical approaches to the oropharynx given the resultant extensive tissue loss. Although no prospective, randomized controlled studies exist to directly compare oncologic outcomes in surgical and nonsurgical approaches, primary radiation or chemoradiation protocols have largely superseded open approaches in previously untreated oropharyngeal cancers. Proponents of TLM and TORS have led a renewed interest in eHNS for the treatment of OPC. As already discussed, both techniques provide excellent access to select tonsillar primaries, whereas the line-of-sight limitations of TLM in tongue-base surgery may be overcome in part by flexible fiberoptic lasers, or avoided by using TORS in these cases.
While currently available oncologic outcomes research that evaluates eHNS in OPC has been retrospective, reported disease-free survival (DFS) and OS rates have been greater than 90% in advanced disease, a finding comparable with historical data for nonsurgical primary treatments. Negative margins at the time of eHNS are critical for obtaining local control.
As previously discussed, the rising epidemic of HPV-associated OPC is a driving force for close scrutiny of primary treatment protocols. These patients tend to be younger with less medical comorbidity relative to HPV-negative OPC. HPV-associated OPC seems to show a greater response to both surgical and nonsurgical treatment modalities. With longer-term survival comes increased susceptibility to late-onset adverse effects of treatment: osteoradionecrosis (in the case of radiation therapy), fibrosis and trismus, dental deterioration, xerostomia with dysphagia, and aspiration. With these considerations the prospective randomized trial ECOG 3311 specifically focuses on HPV-associated OPC, attempting to answer the question whether eHNS may be used to lower the dosage of adjuvant radiation therapy these patients receive, with lower morbidity than open oropharyngeal procedures, and accurate pathologic staging. From this trial it may become evident that eHNS and nonsurgical treatment protocols will frequently be complementary in the treatment of HPV-associated OPC, with the former facilitating reduced radiation dosages.
Role of Endoscopic Head and Neck Surgery in Laryngeal Cancer
TLM is a valuable technique in the treatment of laryngeal cancer, wherein preservation of the uninvolved laryngeal subsites can significantly contribute to posttreatment quality of life. Many centers have adopted TLM for primary treatment of early-stage tumors. Morbidity is reduced and duration of treatment is shorter in TLM when compared with open surgical approaches and radiation therapy, respectively. Even with T1b lesions involving both true vocal folds, unilateral TLM resection followed by a staged contralateral TLM has been advocated, so that anterior commissural webbing is avoided. Although the indications for TLM in more advanced tumors (eg, T3 with preepiglottic invasion) become contentious, local control can be achieved in select cases. Determination of the appropriate T3 patients for TLM must consider whether exposure of the tumor site is attainable, whether the patient can tolerate temporary aspiration, whether the tumor truly is free from cartilage involvement, or whether there is extension into soft tissue of the neck beyond the preepiglottic space. Although the use of TORS in supraglottic and even total laryngectomy has been described previously, significant access limitations exist for sites caudal to the oropharynx, both in visualization and ability to maneuver surgical instruments.
Role of Endoscopic Head and Neck Surgery in Hypopharyngeal Cancer
Hypopharyngeal cancers are often localized to the apical or medial pyriform wall, or postcricoid area, necessitating sacrifice of the adjacent larynx for adequate margins. Often these tumors remain asymptomatic until the advanced stage, another reason why open total laryngectomy with partial or complete pharyngectomy becomes the only surgical option. Primary chemoradiation protocols are widely advocated for hypopharyngeal primaries, given their propensity for submucosal spread that is difficult to surgically clear, and because there is a high risk for regional and distant metastatic disease. Unfortunately pharyngeal strictures, fibrosis, and chondronecrosis of the adjacent larynx do occur in 21% to 37% of chemoradiated patients. The access limitations of eHNS in hypopharyngeal surgery is analogous to the challenges encountered in laryngeal procedures. In the case of hypopharyngeal cancer, however, endoscopic resection of lesions (eg, T1/T2 lesions of the lateral pyriform sinus or posterior hypopharyngeal wall) may mitigate the risk of pharyngocutaneous fistula formation inherent to open pharyngectomy techniques. Although some retrospective studies have described similar DFS and OS rates in TLM or TORS for select cases when compared with open pharyngectomy or concurrent chemoradiation, the biology of this disease is far more aggressive than most oropharyngeal and glottic tumors, and a stronger argument for aggressive multimodality treatment from the onset may be made.
Oncologic outcomes of endoscopic head and neck surgery
Although no prospective studies of oncologic outcomes in TLM or TORS have been reported, several large retrospective studies have been published from multi-institutional collaborations, in addition to a series of informative, but smaller, single-center reports.
Endoscopic Head and Neck Surgery Outcomes for Oropharyngeal Cancer
In one multi-institutional study, Haughey and colleagues reported on 204 patients with stage III and IV OPC who underwent primary TLM with or without adjuvant radiation or chemoradiation. The 5-year OS, disease-specific survival (DSS), and DFS rates were 78%, 84%, and 74%, respectively. HPV and p16 testing was available in 174 of 204 (85%) and 185 of 204 (91%) of patients, respectively. Of those with available testing, 74% and 90% of patients were HPV-positive and p16-positive, respectively. Both p16 and HPV positivity were associated with a significant decrease in risk of death by any cause (hazard ratio 0.11–0.12 and 0.3–0.4) on multivariate analysis, a finding consistent with primary radiation protocol data.
The past decade saw a rapid growth in the application of TORS for the treatment of select OPCs. Oncologic outcomes were comparable with those obtained historically in nonsurgical treatment protocols. Weinstein and colleagues reviewed 47 OPC patients who had undergone TORS, observing a 90% 2-year DSS. In this study local recurrence occurred in 2% of patients. Similarly, White and colleagues studied HNC patients who had undergone TORS, 77 of whom had oropharyngeal primaries (87%). In this study, 3 of 89 (3.3%) patients experienced a local recurrence. Overall recurrence-free survival (RFS) was 86.5% at 2 years. Weinstein and colleagues more recently investigated surgical margin status in a multicenter series of 177 TORS patients, finding 7 of 161 (4.3%) patients with available margin data being positive on final analysis. For historical comparison, in 1978 Byers and colleagues published a series of 216 patients with oral cavity, oropharyngeal, and hypopharyngeal cancers treated with open surgery, achieving negative margins in nearly 90% of cases.
In the largest retrospective multicenter study of oncologic outcomes in TORS to date, 13 institutions collaborated for a pooled analysis of 410 patients, 364 (89%) of whom had OPC. HPV tumor status was available in 229 of 410 (55.9%) patients, of whom 159 (69.4%) were HPV positive. In this series, 43 of 410 (10.5%) patients experienced a locoregional recurrence, and 10 of 410 (2.4%) developed distant metastases. The 2-year and 3-year locoregional control (LRC) rates were 91.8% and 88.8%, respectively. OS at 2 and 3 years was 91% and 87.1%, respectively, with DSS of 94.5% and 92.5%. On multivariate analysis only tobacco use predicted worse OS, whereas tonsillar primary site predicted improved OS. The results of this multicenter study compared favorably with studies of primary radiation therapy in the treatment of OPC, in which LRC ranged from 91% to 97%. No differences in outcomes were observed between HPV-positive and HPV-negative patients, although only 56% of patients had data on HPV status. Furthermore, 91% of patients in this study had early T stage (T2 or less), which could explain in part why no observable differences in survival and l was found between HPV-positive and HPV-negative tumors. In this series early T stage may have been a strong driving force for favorable survival, irrespective of HPV status.
Endoscopic Head and Neck Surgery Outcomes for Laryngeal Cancer
As discussed earlier, TLM has a clear role in early and select advanced laryngeal cancers. A retrospective review of 404 patients with T1 glottic cancers showed a 5-year local control (LC) rate of 86.8%, OS of 87.8%, DSS of 98%, and RFS of 76.1%. In a systematic review of TLM versus primary radiation therapy, Yoo and colleagues found no data in support of one modality over the other, although some studies suggested a higher rate of long-term laryngeal preservation in the TLM group.
When treating supraglottic cancers with TLM, Canis and colleagues achieved a 5-year LC of 85% for T1/T2, 82% for T3, and 76% for T4 tumors, similar to historical rates after open partial laryngectomy. Numerous additional studies have corroborated similar LC in the treatment of T3 laryngeal cancers compared with open partial laryngectomy.
Endoscopic Head and Neck Surgery Outcomes for Hypopharyngeal Cancer
Oncologic results of eHNS for hypopharyngeal cancer have been reported to be comparable with those of open conventional approaches. Martin and colleagues reported the results of TLM in 172 patients with hypopharyngeal carcinoma. Five-year LC was 84% for T1, 70% for T2, 75% for T3, and 57% for T4a tumors. The 5-year RFS for stage I/II, III, and IVa were 73%, 59%, and 47%, respectively. Rudert and Höft reported the outcomes of 29 patients with hypopharyngeal cancer with 5-year OS and DSS of 58% and 48%, respectively. The 5-year OS in stage I/II disease was 71% and in stage III/IV disease 47%. Results of TLM were reported by Karatzanis and colleagues in 119 patients with T1 and T2 cancer of the hypopharynx. The LC was 90% and 5-year DSS 77.8% for T1. In T2 stage disease the LC and 5-year DSS were 83.1% and 70%, respectively. Park and colleagues reported the results of TORS in 23 patients with hypopharyngeal cancer: 3-year OS was 89% and DFS 84%.
Table 2 summarizes the results of the eHNS studies.
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