2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Important Early Advances in Squamous Cell
Carcinoma of the Head and Neck
By Eric Bissada, MD, DMD, Irene Brana, MD, and Lillian L. Siu, MD
Overview: Therapeutic advances in squamous cell carcinomas
of the head and neck (SCCHN) are attained by improvement
in locoregional and/or distant disease control, as well as
by reduction in treatment-related morbidity—especially longterm
complications affecting normal organ functions and
quality of life. New technological innovations in surgical
management, such as transoral robotic surgery (TORS), and in
radiotherapy (RT), such as proton and carbon ion therapy,
bring promises of equal or superior efficacy outcomes coupled
with the potential to minimize normal tissue toxicity. Scientific
THE DELIVERY of precision medicine is relevant in the
management of both early and advanced stages of
SCCHN, not only to improve functional outcomes and disease
control, but also to reduce the burden of acute and
long-term treatment-related morbidity. Technical precision
may be enhanced surgically with the emergence of TORS,
accompanied by the benefit of reduced manipulation of
surrounding normal structures. The use of energy particles
such as protons or carbon ions offers precise RT dose
distributions, thus limiting undesirable scatter to nearby
normal organs. In the systemic treatment of SCCHN, precision
medicine is based on the principles that “druggable”
molecular drivers of sensitivity or resistance exist in cancers,
and that matching of pharmaceutical agents to specific
oncogenic aberrations may improve therapeutic outcome.
The evaluation of these multidisciplinary advances in SCCH
through the conduct of properly designed clinical trials is
necessary to support their application in practice.
Novel Advances in Surgical Management of SCCHN
The Emergence of TORS and Its Potential Benefits in SCCHN
The use of robotic surgery is gaining popularity and is
being applied to several fields including urology, orthopaedic
surgery and cardiac surgery. The latest use of this technology
is in otolaryngology in which some surgeons have found
it helpful for the ablation of difficult-to-access tumors of the
upper aerodigestive tract, particularly oropharyngeal cancers.
TORS is a topic of great interest in head and neck
surgery, and some surgeons believe its popularity will only
increase in the coming years. In TORS, the surgeon sits at a
remote console and controls micromanipulators that in turn
move the arms of a robot placed at the patient’s bedside. A
highly magnified three-dimensional view of the surgical field
is procured with precise, scaled, and filtered motions to the
operating arms. The proponents of TORS state several
benefits over the open approach. The avoidance of a mandibulotomy
and its associated morbidity is clearly the main
advantage this technology offers. Decreased manipulation
and dissection of healthy tissue, improved cosmetic outcome,
decreased need for tracheotomies, early return to oral intake,
and shortened hospital stay are but a few other
potential suggested benefits. 1,2
At present, there are no clear and convincing data to
suggest the superiority of either primary surgery or RT in
terms of disease control and survival benefit for early-stage
oropharyngeal cancer. 3 Functional outcomes and predicted
insights in the systemic treatment of SCCHN, such as novel
approaches to overcome epidermal growth factor receptor
(EGFR) resistance, may enable more effective molecular
targeting in SCCHN beyond the current armamentarium of
available agents. An overarching theme of these early multidisciplinary
advances is to enable the delivery of precisionbased
therapeutic regimens from both the technical and
scientific perspectives. Rigorous clinical trial evaluations are
necessary to help define their roles in practice.
quality of life after treatment have therefore largely been
the determining factors in the choice of therapy offered to
such patients. RT with or without concurrent chemotherapy
is currently the most frequently advocated primary treatment
modality for all stages of oropharyngeal cancer,
whereas surgery is usually reserved for local and/or regional
failures. This stems from the belief that the surgical morbidity
can be more substantial than the anticipated morbidity
from nonsurgical approaches. Speech and swallowing can
be substantially compromised by an open surgical approach
to the oropharynx. This coupled with the fact that patients
may ultimately require adjuvant RT or concurrent chemoradiotherapy
(CRT) has led most head and neck oncologists
to agree that primary RT should serve as the definitive
treatment for these patients.
In contrast to advanced-stage oropharyngeal cancers,
speech and eating quality-of-life outcomes have not shown
any advantage to RT with or without chemotherapy over
surgery followed by adjuvant RT in early-stage T1/T2 disease.
4 With the advent of TORS, surgeons are given a new
and potentially less morbid way of approaching the oropharynx
directly, leading many to reconsider surgery as the
primary treatment in selected cases of oropharyngeal cancers.
Leaving the surrounding structures untouched has led
many surgeons to believe that TORS is less morbid when
compared with conventional open surgical approaches, and
to nonsurgical treatment regimens. Proponents of primary
surgery argue that adjuvant treatment should be based on
operative and pathologic findings tailoring such therapy to
the patients’ needs. Surgically treated early stage T1/T2,
N0/N1 carcinomas of the oropharynx avoided the need for
adjuvant RT in up to 38% of cases without sacrificing disease
control. 5-7 Primary surgery to such tumors enabled a reduction
of the median RT dose to target volumes and prevented
the use of concurrent chemotherapy in many cases. 5,7 TORS
may also decrease target volumes to undissected tissues that
From the Department of Otolaryngology—Head and Neck Surgery, Division of Medical
Oncology and Hematology, Princess Margaret Hospital, University Health Network, Toronto,
Ontario, Canada.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Lillian L. Siu, MD, Division of Medical Oncology and
Hematology, Drug Development Program, Princess Margaret Hospital, 610 University
Avenue, Suite 5-718, Toronto, ON, M5G 2M9, Canada; email: lillian.siu@uhn.on.ca.
© 2012 by American Society of Clinical Oncology.
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