Chairman's Note - Penn Medicine - University of Pennsylvania

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OtOrhinOlaryngOlOgy - head and neck Surgery at the univerSity Of PennSylvania The Evolution of Minimally-Invasive Skull Base Surgery at Penn Medicine The treatment of skull base tumors continues to evolve, and Penn Medicine physicians and researchers are at the forefront of these revolutionary new treatment methods. Skull base tumors including chondrosarcoma, esthesioneuroblastoma, squamous cell carcinoma, adenoid cystic carcinoma, melanoma, meningioma, craniopharyngioma, and chordoma are some of the most challenging, complex and technically demanding tumors to treat. Penn Medicine’s multidisciplinary team of physicians from the departments of Otorhinolaryngology – Head and Neck Surgery, Neurosurgery, Radiation Oncology, Medical Oncology and Neuroradiology are bringing new hope to patients with both malignant and benign tumors of the skull base, sinuses and brain. These worldrenowned physicians are pioneers in the development of minimally-invasive innovative surgical procedures and state-of-the-art imaging. Many tumors previously inaccessible can now be successfully treated. At Penn Medicine’s Center for Cranial Base Surgery, important collaborations continue to grow as well. The department of Otorhinolaryngology – Head and Neck Surgery has six dedicated endoscopic skull base surgeons who work alongside a team of three highly skilled endoscopic skull base neurosurgeons from Penn’s department of Neurosurgery. These national and international leaders are leading the charge in the new millennium of skull base surgery. In addition, our team of surgeons have partnered with our radiation oncologists on a prospective evaluation and study of the role of Proton Beam Radiation Therapy for skull base benign and malignant tumors. We are excited about the potential role of Proton Therapy and how it will synergize with our minimallyinvasive surgical techniques. From the initial skull base surgery team meetings where each patient’s case is discussed and an individualized treatment plan 2 WWW.uPhS.uPenn.edu/PennOrl developed, to the actual surgical procedure, an intuitive, synergistic cohesion has developed that greatly benefits the patients. Penn possesses a powerful arsenal of treatment modalities to combat skull base tumors. One of the things that has been lacking in minimally-invasive endoscopic surgery has been depth perception. An exciting new technology, 3D endoscopy, is taking minimally-invasive surgery to the next level, so that it is quicker, safer, and more efficient. Penn is only one of two or three centers in the entire country to use this technology. The surgery is performed transnasally. A camera creates a 3D view of the surgery, greatly enhancing depth perception and enabling the surgeon to see with stereoscopic vision where it is critical to do so, and improving the ability to do very fine work. The surgeons wear special goggles as if they were watching a 3D movie. Penn continues in its pioneering work in minimally-invasive robotic surgery and is working to develop surgical approaches for the treatment of skull base tumors. Dr. Bert W. O’Malley, Jr., Dr. Gregory S. Weinstein and Dr. Jason G. Newman of the Department of Otorhinolaryngology – Head and Neck Surgery and Dr. M. Sean Grady, Dr. William Welch and Dr. John Y. K Lee of the Department of Neurosurgery are working with industry to improve on technology and create new techniques. From the team that revolutionized the treatment of throat cancers with TransOral Robotic Surgery (TORS), continued groundbreaking procedures are being devised, including the first robotic transoral odontoid surgeries in the world. “Penn Medicine is changing the face of minimally-invasive skull base surgery in the world today. We continue to make strides in developing the latest treatments available to provide the best care for our patients,” said Dr. Newman. Penn International Rhinology and Comprehensive Skull Base Courses The Penn International Rhinology and Comprehensive Skull Base Courses were held from March 11-14, 2010. This course was the 25th anniversary of Penn’s first endoscopic sinus surgery course. This comprehensive program featured an outstanding national and international faculty and focused on medical and surgical advances in the management of sinonasal disease and skull base disorders with specific emphasis on the frontal and sphenoid sinuses, chronic rhinosinusitis, skull base surgery, medical therapy, pediatric sinusitis, image guidance and powered instrumentation and endoscopic management of benign and malignant skull base tumors. Also present was Course Director Heinz Stammberger, MD from Austria, and Penn Medicine Course Directors James N. Palmer, MD; Bert W. O’Malley, Jr., MD; David W. Kennedy, MD; M. Sean Grady, MD; Noam A. Cohen, MD, PhD and Alexander G. Chiu, MD. Courses included live skull base surgery performed by Dr. Palmer, Dr. John Y.K. Lee, and Dr. Kennedy as well as a demonstrated dissection and didactic lectures. Special highlights included a skull base distinguished professor dinner. “This was a fantastic learning experience bringing together skull base surgeons from all over the globe to have input and advance skull base surgery using minimally invasive techniques,” said James N. Palmer, MD, Associate Professor of Otorhinolaryngology – Head and Neck Surgery and Director of Rhinology at Penn Medicine. Mark Your Calendars! The next Penn International Rhinology and Comprehensive Skull Base Course is scheduled for March 10-12, 2011. Hope to see you there!
Continued from Page 1 Data Report – TransOral Robotic Surgery (TORS) outcomes are outpacing the standard of care formerly regarded as the norm in these cases. The standard surgical and nonsurgical approaches to the management of laryngeal, hypopharyngeal and oropharyngeal cancers, while in many ways successful, have significant limitations. Originally the combination of surgery, radiation therapy and chemotherapy was the standard of care. This conventional surgery may require an almost ear-to-ear incision across the throat, or splitting the jaw resulting in speech and swallowing deficits for patients. 1) Paper Accepted in Archives of Otolaryngology, 2010: This paper reported the relapse rate and the survival figures for the entire group with a mean follow-up duration of more than two years. This paper reported that the chance of living and being cured of a cancer in the oropharynx that can be removed by TORS is excellent (90%). It also demonstrates that the chance of the cancer coming back is equal if not greater in the chest than in the neck suggesting that the treatment given to the neck via TORS with or without adjuvant radiation +/- chemotherapy may be more effective than historic results. 2) Paper Accepted in Laryngoscope, 2010: This paper presented a key benefit of TORS as providing pathology information from the surgical specimens that allow the Head and Neck team to better stratify and justify patients for adjuvant chemotherapy and radiotherapy. In contrast to the situation where TORS and neck dissections are not performed, all patients with lymph node metastases would receive chemotherapy. Our data showed that up to 70% of patients undergoing TORS were not recommended for chemotherapy based on negative primary site margins and limited neck disease. The use of surgery, TORS, and pathology information allows for tailored therapy and recommendations for adjuvant radiation and/or chemotherapy. EXCELLENCE IN PATIENT CARE, EDUCATION AND RESEARCH SINCE 1870 In contrast, TORS outcomes and the patient’s quality of life are markedly improved when compared to the standard results. Benefits to patients that undergo TORS can include no dependence on G-tubes for nutrition, shorter hospitalization, a quicker return to normal activity, fewer complications compared to traditional open surgery, less scarring than traditional open surgery, less risk of blood transfusion, and no routine use of tracheostomy during surgery compared to routine use for open surgery. 3) Paper Accepted in Head and Neck, 2010: It is now recognized that cancers in the oropharynx (tonsil and base of tongue) can either be related to traditional exposure to tobacco products or to the infection of certain high risk strains of the human papillomavirus that can itself cause cancers. The two are not mutually exclusive but it is now understood that oropharynx cancers associated with HPV have a better prognosis regardless of how they are treated. That is, these cancers are less likely to return whether they are treated surgically or with radiation therapy. In contrast, the HPV negative oropharynx cancers do not do as well. This study investigated the results when the cancers were tested for the presence of certain high risk strains of the human papillomavirus. The results are limited by the fact that only 50 patients were studied but are potentially very provocative. The study demonstrated that the HPV positive tumors did well as would be expected. However, the HPV negative tumors appear to be doing better than what would historically be expected. This suggests that HPV negative tumors MAY be better suited when treated with upfront surgery such as TORS which allows for surgery in this area without significantly increasing the risk of swallowing complications. 4) Paper Accepted in Journal of Robotic Surgery, 2010: This review paper helps to summarize how the use of TORS is defining a new treatment approach with what appears to be more benefits than risks and may be a way “These successful outcomes and the new supporting data reflect the exciting fact that TORS is on its way to becoming the new standard of care in the treatment of head and neck cancer patients,” said Dr. O’Malley. The journal articles listed below submitted by the Department of Otorhinolaryngology – Head and Neck Surgery at Penn Medicine further illustrate these exciting new outcomes due to the TORS procedure. Papers listed include those accepted and under review in a variety of medical journals within the discipline. in which to further reduce the risk of late swallowing complications compared to the use of chemoradiation for all locally advanced oropharynx cancers. 5) Paper Accepted in International Journal of Head and Neck Surgery, 2010: This review paper summarizes the current indications for the use of TORS for various benign and malignant tumors of the head and neck. This reflects the Penn experience and the experience of other institutions that are also beginning to publish their results, results which appear to be consistent with the results seen at Penn to date. This helps to further validate that this approach is potentially generalizable to other institutions. 6) Paper Accepted in the Journal of Oto-Rhino-Laryngology, ORL, 2010: This review paper summarizes the historical development of the use of adjuvant radiation therapy with or without the use of chemotherapy. It also summarizes the unique implications that TORS has when deciding on what extra treatment should be used after TORS given the pathology findings. The study also helps to identify important questions that are still unanswered and where future research efforts can be placed. 7) Study In Progress, 2010-2011: A larger study is underway which is designed to confirm preliminary findings that the risk of long-term swallowing complications necessitating nutrition through a gastrostomy feeding tube is 0% with TORS. v O l u m e 5 - fa l l/Winter 2010 3
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Chairman's Note - Penn Medicine - University of Pennsylvania

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